REPORT TO CONGRESS

Traumatic Brain Injury In the United States:

Epidemiology and Rehabilitation

Submitted by the Centers for Disease Control and Prevention

National Center for Injury Prevention and Control

Division of Unintentional Injury Prevention 
The Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation is a publication of the 

Centers for Disease Control and Prevention (CDC), in collaboration with the National Institutes of Health (NIH).

Centers for Disease Control and Prevention

National Center for Injury Prevention and Control

Thomas R. Frieden, MD, MPH

Director, Centers for Disease Control and Prevention

Debra Houry, MD, MPH

Director, National Center for Injury Prevention and Control

Grant Baldwin, PhD, MPH

Director, Division of Unintentional Injury Prevention

The inclusion of individuals, programs, or organizations in this report does not constitute endorsement by the Federal 

government of the United States or the Department of Health and Human Services (DHHS).

Suggested Citation: Centers for Disease Control and Prevention. (2015). Report to Congress on Traumatic Brain Injury in the 

United States: Epidemiology and Rehabilitation. National Center for Injury Prevention and Control; Division of Unintentional 

Injury Prevention. Atlanta, GA. 
Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . 1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Public Health Impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

TBI Health Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Effectiveness of TBI Outcome Measures . . . . . . . . . . . . . . . . . . 3

Factors Influencing Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . 4

Effectiveness of TBI Rehabilitation . . . . . . . . . . . . . . . . . . . . . . 4

Cognitive Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Physical Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Recommendations..

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Section I: Epidemiology and Consequences 

of TBI in the United States . . . . . . . . . . . . . . . . . . 15

Definition of TBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Characteristics of TBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Injury Severity Classification of TBI . . . . . . . . . . . . . . . . . . . . . 17

Health and Other Effects of TBI . . . . . . . . . . . . . . . . . . . . . . . . 18

Burden of TBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Unique Considerations for Specific Populations . . . . . . . . . . . 21

Gaps in Determining the Incidence of TBI . . . . . . . . . . . . . . . . 23

Gaps in Determining the Prevalence of Persons with 

TBI-related Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Recommendations...

Section II: Effectiveness of TBI 

Outcome Measures . . . . . . . . . . . . . . . . . . . . . . . 27

Importance of Outcome Measurement . . . . . . . . . . . . . . . . . . 27

The Common Data Elements Project . . . . . . . . . . . . . . . . . . . . 27

TRACK-TBI Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

The Pediatric Common Data Elements Project . . . . . . . . . . . . . 30

Factors Influencing Outcomes . . . . . . . . . . . . . . . . . . . . . . . . 31

Gaps in TBI Outcome Measurement . . . . . . . . . . . . . . . . . . . . 33

Recommendations...

Section III: TBI Rehabilitation . . . . . . . . . . . . . . . 37

Goals and Purpose of Rehabilitation . . . . . . . . . . . . . . . . . . . 37

Effectiveness of TBI Rehabilitation Practices . . . . . . . . . . . . . . 37

Gaps in Evaluating the Effectiveness of TBI Rehabilitation . . . . 44

Recommendations...

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Appendix A: Authors, Panel Members, 

Consultants, and Subject Matter Experts . . . . . . 53

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
iv CENTERS FOR DISEASE CONTROL AND PREVENTI
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 1

Executive Summary

The Traumatic Brain Injury Act of 2008 authorized research and public health activities related to traumatic brain injury 

(TBI). The goal of public health related to injury prevention is to reduce the burden of injury at the population level by 

preventing injuries and ensuring care and rehabilitation that maximizes the health and quality of life for injured persons. 

The purpose of this report is to review what is known about TBI in three areas:

TBI BURDEN

➤ Describe the incidence of TBI, including trends over time;

➤ Describe data on the prevalence of TBI-related disability;

TBI OUTCOMES

➤ Review the adequacy of TBI outcome measures;

➤ Describe factors that influence differential TBI outcomes;

TBI REHABILITATION

➤ Assess the current status and effectiveness of TBI rehabilitation services.
2 CENTERS FOR DISEASE CONTROL AND PREVENTIO

Introduction

A TBI is an injury that disrupts the normal function of the 

brain. It can be caused by a bump, blow, or jolt to the head 

or a penetrating head injury (Marr and Coronado, 2004). 

Explosive blasts can also cause TBI, particularly among 

those who serve in the U.S. military. In 2010, the Centers 

for Disease Control and Prevention (CDC) estimated that 

TBIs accounted for approximately 2.5 million emergency 

department (ED) visits, hospitalizations, and deaths in the 

United States, either as an isolated injury or in combination 

with other injuries. Of these persons, approximately 

87% (2,213,826) were treated in and released from EDs, 

another 11% (283,630) were hospitalized and discharged, 

and approximately 2% (52,844) died. However, these 

numbers underestimate the occurrence of TBIs. They do 

not account for those persons who did not receive medical 

care, had outpatient or office-based visits, or those who 

received care at a federal facility, such as persons serving 

in the U.S. military or those seeking care at a Veterans 

Affairs hospital (Faul et al., 2010). Those who serve in the 

U.S. military are at significant risk for TBI as Department 

of Defense data revealed that from 2000 through 2011 

235,046 service members (or 4.2% of the 5,603,720 who 

served in the Army, Air Force, Navy, and Marine Corps) 

were diagnosed with a TBI (CDC, NIH, DoD, and VA 

Leadership Panel, 2013).

Classification

The severity of TBI can be classified as mild, moderate, 

or severe on the basis of clinical presentation of a patient’s 

neurologic signs and symptoms. The symptoms of TBI 

vary from one person to another, and although some 

symptoms might resolve completely, others, especially as a 

result of moderate and severe TBIs, can result in symptoms 

that persist, resulting in partial or permanent disability. 

The assessment of TBI-related health effects is vital for the 

delivery of medical care, for discharge planning, inpatient 

treatment, and rehabilitation. Some health effects of TBI 

in children, such as deficits in organization and problemsolving, might be delayed, and not surface until later. 

As a result, for both adults and children, TBI is being 

recognized more as a disease process, rather than a discrete 

event, because of the potential it presents for non-reversible 

and chronic health effects (Masel and DeWitt, 2010).

Public Health Impact

A TBI can adversely affect a person’s quality of life in 

numerous ways, including cognitive, behavioral/emotional, 

and physical effects that affect interpersonal, social and 

occupational functioning. In addition to the impact of 

TBI on the individual, TBI can negatively impact families, 

communities, and the economy. Although data are limited, 

estimates based on data from two states indicate that 

3.2 million–5.3 million persons in the United States 

are living with a TBI-related disability (Selassie, et al., 

2008; Thurman, Alverson, Dunn, Guerrero, and Sniezek, 

1999; Zaloshnja, Miller, Langlois, and Selassie, 2008). 

Additionally, adolescents and adults affected by moderate 

or severe TBI who were discharged from rehabilitation 

facilities were more than twice as likely to die 3.5 years after 

injury compared to persons in the general population of 

similar age, sex, and race (Harrison-Felix et al., 2012). Also, 

among adolescents and adults who received rehabilitation 

for TBI, 2 in 10 will have died at 5 years post-injury, and 

nearly 4 in 10 will have declined in function from the level 

of recovery attained 1–2 years after their injury (Corrigan, 

et al., 2014). These findings point to the chronic health 

effects of TBI that can affect a person’s health and social 

environment long after acute medical treatment 

and rehabilitation. 

In the United States, children aged 0–4 years, adolescents 

aged 15–19 years, and adults aged 75 years and older are 

among the most likely to have a TBI-related emergency 

department visit or to be hospitalized for a TBI (Faul et 

al., 2010). Adults aged 75 years and older have the highest 

rates of TBI-related hospitalizations and deaths among 

all age groups. The leading causes of non-fatal TBI in the 

United States are falls (35%), motor vehicle-related injuries 

(17%), and strikes or blows to the head from or against an 

object (17%), such as in sports injuries (Faul et al., 2010). 

The leading causes of TBI-related deaths are motor vehicle 

crashes, suicides, and falls (Coronado et al., 2011). 
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 3

TBI Health Effects

A TBI can result in health effects that vary in intensity, 

length, and clinical manifestation. These health effects 

can persist and contribute to potential impairment, 

functional limitation, disability, and reduced quality of 

life (Riggio and Wong, 2009; Walker and Pickett, 2007). 

Disturbed cognition is the hallmark symptom of TBI but 

the injury also can affect behavior, emotion, and motor 

function. Cognitive disturbances can lead to difficulties 

with memory, attention, learning, and coordination. Other 

signs and symptoms include headaches, fatigue, and sleep 

disturbances. In addition, secondary neurologic disorders 

such as mood disorders and post-traumatic epilepsy can 

occur following TBI and disrupt health-related quality 

of life (Rosenthal, Christensen, and Ross, 1998; Hart, 

Brenner, Clark, Bogner, Novack, Chervoneva, NkaseRichardson, and Arango-Lasprilla, 2011; Lowenstein, 

2009; Agrawal, Timothy, Pandit, and Manju, 2006). The 

scientific literature also suggests that TBI increases the 

risk for neurodegenerative disorders, such as dementia. 

However, a majority of persons, particularly those with 

mild TBI, will generally experience one or more of 

these health effects for a short time following the injury. 

Repeated TBIs, though, can have prolonged and long-term 

effects. Finally, TBI can negatively affect families. Adverse 

family effects can include caregiver distress, depression, and 

deterioration of family functioning after a TBI (Aitken et 

al., 2009; Wade, Carey, and Wolfe, 2006b). 

Effectiveness of TBI Outcome 

Measures

TBI outcome measures can be broadly defined as 

instruments or scales that assess physical and cognitive 

ability, as well as psychological functioning, after the 

injury. There can be a wide range of short- and long-term 

outcomes resulting from a TBI. Accurately measuring these 

outcomes is critical given the important purposes for which 

measurement results are used. First, outcome measurement 

helps assess the status of recovery and effectiveness of 

rehabilitation. Second, measurement results can be used 

to monitor the progress of treatment in the clinical setting 

and demonstrate treatment progress to a third-party 

payer. Finally, these outcomes undergird research on the 

effectiveness of TBI rehabilitation and better inform future 

clinical interventions and recovery. 

The TBI Outcomes Workgroup of the 

Common Data Elements (CDE) Project 

identified the critical outcome domains for 

TBI outcomes research (Wilde et al., 2010) 

as follows:

➤ Global Outcome

➤ Recovery of Consciousness

➤ Neuropsychological Impairment

➤ Psychological Status

➤ TBI-related Symptoms

➤ Behavioral Function

➤ Cognitive Activity Limitations 

➤ Physical Function

➤ Social Role Participation 

➤ Health-Related Quality Of Life 

➤ Health-Economic Measures 

➤ Patient-Reported Outcomes

The TBI CDE Outcomes Workgroup also identified 

a set of recommended measures within each outcome 

domain. These recommended measures were those with 

the strongest level of research support. However, these 

measures require several hours to implement. One of 

the current goals of the National Research Action Plan 

(NRAP), a federal interagency group that is charged with 

coordinating TBI research, is the development of a shorter 

but comprehensive assessment tool that is sensitive across 

the range of TBI severities. In addition, the authors of the 

NRAP have acknowledged that the limited effectiveness 

demonstrated by previously conducted intervention 

studies, including those in rehabilitation, have been caused 

in part by the limited number of validated assessment tools 

that are sensitive enough to detect treatment effects. The 

TBI CDE Outcomes Workgroup also identified several 

measures within each domain that are promising and that 

have the potential to surpass the currently recommended 

measures. The TBI CDE Outcomes Workgroup indicated 

that these measures require additional study to warrant 

inclusion as a recommended tool to assess a particular 

element within an outcome domain.

A separate pediatric workgroup identified additional CDEs 

and associated measures for children, specifically related 
4 CENTERS FOR DISEASE CONTROL AND PREVENTIO

to academics, adaptive and daily living skills, family and 

environment, language and communication, and social 

cognition (McCauley et al., 2012). 

The taxonomy developed by the TBI CDE Outcomes 

Workgroup has the potential to bring greater consistency 

to TBI-related outcomes that will improve the quality and 

comparability of TBI research.

Finally, a multicenter study, Transforming Traumatic 

Brain Injury Research and Clinical Care (TRACK-TBI), 

evaluated the feasibility of implementing a wide range of 

the TBI CDEs in a single study of adults with TBI. This 

study found that assessing a large number of TBI CDEs 

was feasible. However, several gaps in the study were 

identified, including the need for validating additional 

outcome measures for TBI patients living with higher levels 

of disability and the need for validating additional outcome 

measures among non-English speaking patients.

Factors Influencing Outcomes 

Intervening factors that have been shown to influence 

outcomes must be considered when interpreting research 

examining the effectiveness of rehabilitation. Aside 

from the type and severity of a TBI, and the medical 

care received, recovery from TBI is influenced by factors 

including individual patient characteristics, socialenvironmental factors, and access to rehabilitation services. 

Individual characteristics, such as age and pre-injury 

functioning, can influence outcomes after TBI. The 

degree to which they influence outcomes depends upon 

the severity of injury. Social-environmental factors (e.g., 

socioeconomic status, social support, caregiver and family 

functioning) also can influence outcomes after TBI. Finally, 

access to rehabilitation services can be negatively impacted 

by a lack of specialty providers, particularly in rural areas, 

as well as a lack of financial resources available to a person 

with TBI. The availability and level of insurance coverage 

are especially important. 

Effectiveness of TBI Rehabilitation

Following hospitalization for a TBI, persons can receive 

rehabilitation care and services in various settings. Postacute rehabilitation is provided following an inpatient 

hospital stay and is typically indicated for persons whose 

medical condition requires continued skilled nursing 

care. Some settings in which this level of rehabilitation is 

available includes inpatient rehabilitation facilities, longterm care hospitals, and skilled nursing facilities. Persons 

who no longer require skilled nursing care are usually 

discharged home and may receive rehabilitation care 

provided by outpatient and community service centers. 

However, the type of rehabilitation care or setting selected 

is also based on a person’s level of functional recovery, 

independence, geographic availability, and financial 

resources—including insurance coverage.

For persons living with TBI-related health effects, 

rehabilitation goals are structured to improve their 

independence in activities of daily living, social functioning, 

quality of life, and ability to participate in the community. 

They typically focus on the recovery of motor function, 

cognitive function, self-care skills, and community 

participation. A person’s pre-injury functioning and 

personal goals are fundamental in determining the best 

rehabilitation treatment plan, as well as the eventual 

outcomes. No single TBI rehabilitation program will 

work for all patients; rather, the goals and methods of 

rehabilitation must be individualized to each person.

TBI rehabilitation consists of therapies broadly categorized 

as cognitive and physical. Cognitive rehabilitation (CR) 

consists of a group of therapies used to manage deficits 

in thought processes and behavior (e.g., comprehension, 

perception, and learning). Physical rehabilitation focuses 

on enhancing different forms of mobility by improving 

physical factors such as strength and endurance, as well as 

providing assistive devices that facilitate independence. 
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 5

Cognitive Rehabilitation

The Cognitive Rehabilitation (CR) Task Force of the 

American Congress of Rehabilitation Medicine (ACRM) 

Brain Injury Interdisciplinary Special Interest Group 

evaluated 370 studies and found that CR is effective during 

the post-acute period—even 1 year or more after injury 

(Cicerone et al, 2000, 2005, 2011). Further analysis of the 

scientific literature suggests that CR is effective in patients 

with moderate and severe TBI (Rohling et al., 2009). 

However, an Institute of Medicine (IOM) committee 

concluded that the evidence was insufficient to provide 

practice guidelines, particularly with respect to selecting the 

most effective treatments for a specific person (IOM, 2011). 

The insufficiency of the evidence was largely attributed to 

limitations in research designs for rehabilitation evaluation 

studies. And yet, empirical support for CR is growing 

with the strongest level of evidence for the following 

interventions (Cicerone et al., 2011):

➤ Direct attention training 

accompanied by metacognitive 

training to promote development 

of compensatory strategies and 

generalization;

➤ Interventions to address functional 

communication deficits and 

memory strategies for mild memory 

impairments; 

➤ Meta-cognitive strategies for 

executive function deficits; and 

➤ Comprehensive holistic 

neuropsychological rehabilitation. 

Preliminary evidence supports the effectiveness of 

group-based rehabilitation treatment of pragmatic 

communication disorders. However, research that 

demonstrates the effectiveness of cognitively based 

treatments for listening, speaking, reading, and writing, in 

social, educational, occupational, and community settings is 

lacking (Turkstra et al., 2003). 

Physical Rehabilitation

Evidence supports the general effectiveness of physical 

rehabilitation (Bland, Zampieri-Gallagher, and Damiano, 

2011; Betker, Desai, Nett, Kapadia, and Szturm, 2007; 

Irdesel, Aydiner, and Akgoz, 2007; Mossberg, Amonette, 

and Masel, 2010; Scherer and Schubert, 2009; Shaw et 

al., 2005). With respect to specific interventions, regularly 

scheduled passive range-of-motion exercises and body 

re-positioning are techniques that are commonly used 

with positive effects (Winkler, 2013). Equipment, such as 

standing frames or tilt tables, can be used to maintain bone 

structure, elongate shortened muscles, challenge endurance, 

and stimulate the minimally conscious person. Bodyweight-supported (BWS) gait devices and knee-ankle-foot 

orthotics can be used with manual assistance to initiate 

standing postures. BWS devices can lead to improved 

cardiovascular function and assist with the beginning of 

walking training (Mossberg, Orlander, and Norcross, 2008; 

Wilson and Swaboda, 2002).

Gaming and virtual reality-based treatment methods are 

emerging as an adjunct to physical therapy standards of 

practice for treating persons with TBI (Betker et al., 2007; 

Scherer and Schubert, 2009). One study demonstrated 

the effectiveness of improved goal-oriented, task-specific 

training with the use of a gaming system to promote 

practice of short sitting balance control for persons with 

TBI. Another method used a game-based training tool 

that yielded an increase in practice volume and attention 

span, and furthermore, improvements in dynamic sitting 

balance control (Betker et al., 2007). Certain evidence 

indicates that virtual reality and other methods to improve 

vestibular function and balance result in improvements in 

both gait and gaze stability of persons with TBI sustained 

during blasts (Scherer and Schubert, 2009). However, 

approaches such as motor interventions, proprioceptive 

muscle training, and neurodevelopmental treatment have 

been used in clinical practice with limited research on their 

effect on functional outcomes.
6 CENTERS FOR DISEASE CONTROL AND PREVENTIO

Recommendations

The following section lists recommendations to address gaps identified in each of the major sections in this report. The full 

report provides additional background and describes the critical gaps that are addressed by the following recommendations: 

Section I. Epidemiology and Consequences of TBI in the United States

➤ Improve TBI incidence and prevalence estimates to include patients with TBI who are 

treated in non-hospital settings and those with TBI who are not receiving medical care. 

Develop or identify sources of non-hospital TBI incidence data, such as data from 

physician offices and other sources of outpatient medical encounters, to improve 

estimates. Similarly, develop or identify data sources that capture information from 

persons who might have experienced a TBI but did not seek medical care for 

their injury. 

➤ Generate state-specific TBI estimates. Collect and compile health care administrative 

data in all states to quantify and examine state-level variations in TBI burden. In 

addition, state-level TBI estimates can be used to inform decisions related to the 

allocation of preventive and rehabilitative services that are made at the state level.

➤ Better understand injury mechanisms and their effect on sub-populations. Examine 

trends in TBI incidence by injury mechanism and within population subgroups (e.g., 

children, older adults, and others) by using data systems such as Healthcare Cost 

Utilization Project (HCUP). This can help target prevention resources to populations at 

greatest risk for TBI.

➤ Enhance monitoring of sports and recreation concussions. Develop and implement a 

concussion surveillance system that captures the full range of sports- and recreationrelated concussions. Current surveillance systems capture only emergency department 

visits or injuries experienced in organized high school sports, collegiate athletics, and 

some professional leagues.

➤ Produce population-level estimates of TBI-related disability. Add TBI-related disability to 

large, existing national health surveys, and analyze large-scale claims or administrative 

datasets to produce population-level estimates. 
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 7

Section II. Effectiveness of TBI Outcome Measures

➤ Develop comprehensive outcome measures that enable measurement of treatment 

effectiveness specific to the TBI population. It is essential to develop tools that are 

sensitive to changes associated with treatment and rehabilitation regardless of 

TBI severity.

➤ Increase validation of outcome measures in sub-populations. Conduct validation studies 

of outcome measures among particular sub-populations in which validity, reliability, 

and sensitivity have not been assessed previously. This practice is critical to expand 

scientific knowledge of outcomes and establish best practices for sub-populations, 

such as children, where evidence is still developing. 

➤ Better leverage health information technology (IT). Examine the expanding use of 

electronic health records as 1) a method for tracking patient progress from one level or 

system of care to another and 2) as a way to better examine the effectiveness of TBI 

interventions. 

➤ Create additional outcome measures that can be administered readily to non-native 

English speakers. The TRACK-TBI study found that a number of the measures 

recommended by the TBI CDE Workgroup could not be administered to non-native 

English speakers.

➤ Test and adapt the CDEs for children and adolescents. Similar to how the TRACK-TBI 

study examined the feasibility of implementing the CDEs in adults, a need exists 

for examining the feasibility of assessing the full range of CDEs among children 

and adolescents. 

➤ Assess promising Common Data Element Outcomes measures. Conduct additional 

studies of the measures the TBI CDE Workgroup identified as promising to determine 

whether they might warrant inclusion as recommended measures. 

➤ Enhance involvement of patients and families in assessing rehabilitation outcomes. 

Increase inclusion of patient- and family-centered outcomes in research studies to 

better document the real-world utility of rehabilitation.

(continued on next page)
8 CENTERS FOR DISEASE CONTROL AND PREVENTIO

Section III. Effectiveness of TBI Rehabilitation

➤ Improve understanding of optimal rehabilitation protocols. Conduct research studies to 

better examine the optimal timing, intensity, and dose of rehabilitation interventions. 

➤ Study rehabilitation effectiveness among sub-populations. Conduct research studies 

to determine the effectiveness of TBI rehabilitation services among groups in which 

effectiveness has not been specifically examined, such as children. Examining 

effectiveness among specific sub-populations can help to identify ways in which 

rehabilitation might be tailored to the particular needs of sub-groups to optimize 

effectiveness.

➤ Create service models for parents and caregivers to optimize rehabilitation services.

Develop and evaluate service models that will assist parents to better navigate the 

post-acute rehabilitation setting, ensuring that needed services for children with TBI 

are received. 

➤ Strengthen understanding of TBI continuum of care after acute inpatient rehabilitation. 

Conduct research studies to examine the effectiveness of rehabilitation services 

following acute inpatient rehabilitation, such as community-based rehabilitation and 

vocational rehabilitation. 

➤ Further assess the cost benefit of TBI rehabilitation to enhance understanding of cost 

effectiveness. Conduct studies examining the cost-benefit ratio of TBI rehabilitation 

interventions and examine how the cost-benefit ratio is related to the dose, duration, 

and intensity of rehabilitation. Beyond demonstrating the health-related effects 

of rehabilitation, the effectiveness of TBI rehabilitation can also be supported by 

documenting the resulting economic benefit. 

➤ Further assess the need to increase use of alternative sources for delivering 

rehabilitation services, such as telemedicine, tele-health, mobile services, and the use 

of lay health advisors. Evaluate the effectiveness and cost effectiveness of alternative 

delivery models—especially those that might overcome barriers to rehabilitation access 

caused by factors that include rural residence and lack 

of transportation.

➤ Implement integrated systems to support the ongoing follow-up of persons affected by TBI.

Develop healthcare models that integrate medical and community services that support 

the lifelong needs of persons affected by TBI.

➤ Expand use of promising technologies for use in rehabilitation interventions. Increase 

widespread dissemination of emerging practices such the use of web-based 

consultation, as well as global positioning system devices, paging systems, and 

smartphones to aid with cognitive rehabilitation.

Recommendations (continued)
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 9

Conclusion 

Understanding the epidemiology of TBI, its associated 

consequences, and the availability and effectiveness of 

rehabilitation interventions are crucial to improving 

the quality of life of those with a TBI. The most recent 

estimates of the burden of TBI suggest a decrease in TBIrelated deaths, likely related to fewer motor vehicle-related 

TBIs. In contrast, TBI-related emergency department 

visits have increased, although this may be due in part to 

increased awareness of concussions among the general 

public. Nevertheless, the public health and economic 

burden of TBI is substantial and primary prevention 

remains the key public health strategy to reduce the 

burden of TBI. However, because preventing all TBIs 

is impractical, an imperative for those in public health 

practice, clinical practice, and research is to design and 

evaluate effective strategies to mitigate the health effects of 

TBI. Maintaining a comprehensive and coordinated system 

of rehabilitation interventions is critical to achieve this end. 

Substantial progress has been made in identifying effective 

rehabilitation interventions after a TBI, but considerable 

work remains to be done. 

CDC was asked by Congress to address the need for 

evidence-based guidelines for TBI rehabilitation. Although 

previous research has demonstrated the broad effectiveness 

of a number of TBI rehabilitation services, additional 

research is needed before evidence-based guidelines can 

be developed. The heterogeneous nature of TBI injuries 

and TBI rehabilitation imposes challenges to identifying 

the specific conclusions that can be translated into 

recommendations for clinical use. These challenges must be 

addressed to improve the evidence base before embarking 

on guideline development.

Signs of extensive progress in TBI rehabilitation research 

are evident. Chief among these are the efforts of the TBI 

Common Data Elements Project and the TRACK-TBI 

study, as both are steps forward in improving the quality 

and comparability of future TBI outcomes research. Such 

coordinated effort is required to move the evidence base 

forward to better help persons with TBI to lead more 

healthy and productive lives.
10 CENTERS FOR DISEASE CONTROL AND PREVENTIO
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 11

Background

“The brain is more than an assemblage of autonomous modules, each crucial 

for a specific mental function. Every one of these functionally specialized areas 

must interact with dozens or hundreds of others, their total integration creating 

something like a vastly complicated orchestra with thousands of instruments, 

an orchestra that conducts itself, with an ever-changing score and repertoire.” 

— Oliver Sacks

Physician, author, and professor of neurology 
12 CENTERS FOR DISEASE CONTROL AND PREVENTIO

Introduction

The Traumatic Brain Injury Act of 2008 [P.L. 110-206 

(S. 793, H.R. 1418); U.S. Government Printing Office, 

2008] authorized research and public health activities 

related to TBI. Part J of Title III of the Public Health 

Service Act (42 U.S.C. 280b et seq.) was amended by 

inserting section 393C-1 entitled Study on Traumatic Brain 

Injury. This section authorized CDC to conduct a study 

in collaboration with the National Institutes of Health 

(NIH) and other appropriate entities to complete the 

following, subject to the availability of information:

1. Determine the incidence of TBI and 

prevalence of TBI-related disability and 

the clinical aspects of the disability in all 

age, racial, and ethnic minority groups 

in the general population of the United 

States;

2. Report national trends in TBI;

3. Identify common interventions used 

for rehabilitation and determine their 

effectiveness;

4. Analyze the adequacy of existing 

measures of outcomes and knowledge of 

factors influencing differential outcomes; 

5. Identify interventions and therapies 

that can prevent or remediate the 

development of secondary neurologic 

conditions related to TBI; and,

6. Develop guidelines for patient 

rehabilitation after TBI.

The first section of this report describes the epidemiology 

of TBI, including incidence and trends (Items 1 and 2 

from above). The second section examines TBI outcomes 

measurement and the factors that have been associated 

with differential outcomes (Item 4 from above). The third 

section describes TBI rehabilitation interventions and 

their effectiveness (Items 3 and 5 from above). Finally, 

the Conclusion section outlines the critical gaps that 

impede the development of evidence-based guidelines for 

rehabilitation after TBI occurs. 

Purpose

The goal of public health related to injury prevention is 

to reduce the burden of injury at the population level by 

preventing injuries and assuring care and rehabilitation that 

maximizes the health and quality of life for injured persons. 

The purpose of this report is to review what is known 

about TBI in the following three areas: 

TBI BURDEN

➤ Describe the known incidence of TBI, 

including trends over time;

➤ Describe data on the prevalence of 

TBI-related disability;

TBI OUTCOMES

➤ Review the adequacy of TBI outcome 

measures;

➤ Describe factors that influence 

differential TBI outcomes; 

TBI REHABILITATION

➤ Assess the current status and 

effectiveness of TBI rehabilitation 

services. 

In this report, critical gaps and challenges related to these 

topics are described and recommendations for addressing 

these gaps are identified.
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 13

Method

In October 2011, CDC convened a panel of specialists 

in TBI rehabilitation to devise a plan for addressing 

the language within the TBI Act of 2008 related to the 

Study on Traumatic Brain Injury. Participants included 

psychologists, physical medicine and rehabilitation 

physicians, physical and occupational therapists, 

speech-language pathologists, and federal specialists 

and representatives from CDC, NIH, Department of 

Defense (DoD), Department of Education (DOE), 

and Department of Veterans Affairs (VA). Additional 

authorities served as consultants and subject matter experts 

during the review process (Appendix A). 

Panel participants concluded that two recently published 

systematic reviews—one by the Institute of Medicine 

(IOM) on cognitive rehabilitation and one by the Agency 

for Healthcare Research and Quality (AHRQ) on 

multidisciplinary post-acute rehabilitation (Brasure et al., 

2012; Institute of Medicine [IOM], 2011)—contained 

supporting information for at least some of the questions 

posed. In addition, the panel decided that their work 

should focus on building upon these and other publications 

(e.g., Gordon et al., 2006). 

As a result, the methodology employed was a broad-based 

review of the literature. This methodology included studies 

that might not have met the criteria used in systematic 

reviews, such as literature examining emerging and current 

“best practices” in TBI rehabilitation. 

The panel conducted its work through working groups 

composed of CDC staff and external panelists. The panel 

developed the initial outline of the report and working 

groups were formed to focus on the following topics: 

special populations, TBI outcome measures, delivery of 

TBI rehabilitation services, and the effectiveness of TBI 

rehabilitation practice. Both CDC staff and panelists 

contributed to identifying and reviewing literature in each 

of these areas. 

This report reflects CDC’s synthesis of these activities.
14 CENTERS FOR DISEASE CONTROL AND PREVENTIO
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 15

SECTION I

Epidemiology and Consequences of TBI 

in the United States

Definition of TBI 

CDC defines TBI as a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head 

or a penetrating head injury (Marr and Coronado, 2004). Explosive blasts can also cause TBI, particularly among those who 

serve in the U.S. military. Observing one of the following clinical signs constitutes an alteration in brain function (Menon, 

Schwab, Wright, and Maas, 2010): 

a. Any period of loss of or decreased consciousness;

b. Any loss of memory for events immediately before (retrograde amnesia) or after the injury 

(post-traumatic amnesia);

c. Neurologic deficits such as muscle weakness, loss of balance and coordination, disruption 

of vision, change in speech and language, or sensory loss;

d. Any alteration in mental state at the time of the injury such as confusion, disorientation, 

slowed thinking, or difficulty with concentration.

Not all bumps, blows, or jolts to the head result in TBI. Additionally, not all persons who experience a TBI will have 

behavioral effects or a TBI-related disability (Corrigan, Selassie, and Orman, 2010). However, the combination of several 

factors—trauma from the head striking or being struck by an object, an object penetrating the brain, acceleration/

deceleration movement of the brain not caused by direct trauma to the brain, and the presentation of signs and symptoms 

of TBI either immediately or shortly after the suspected event—is sufficient to classify a person as having sustained a TBI 

(Corrigan, et al., 2010). 
16 CENTERS FOR DISEASE CONTROL AND PREVENTIO

Characteristics of TBI 

Classification of TBI based on patterns and types of injury 

is important to ensure proper treatment and long-term 

therapy. However, the complexity of TBI and limitations of 

available assessment tools make this challenging (Marshall 

et al., 1992). A primary brain injury occurs immediately 

after impact and is a direct result of mechanical trauma. 

Depending on the injury mechanism and severity, the 

initial event might cause direct, primary physical alterations 

of the brain tissue. A secondary brain injury can occur 

hours or days after the initial traumatic event and can arise 

from complications initiated by the primary injury such 

as inflammation, cell receptor-mediated dysfunction, free 

radical and oxidative damage, and calcium or other ionmediated cell damage (Graham, Gennarelli, and McIntosh, 

2002; Greve and Zink, 2009; Werner and Engelhard, 

2007). Cerebral edema, or brain swelling, is a common 

secondary brain injury and a frequent cause of brain death 

in persons with severe TBI (Plesnila, 2007).

As in other tissue injuries, an inflammatory reaction to TBI 

can occur. Inflammation is involved in the repair of brain 

tissue after injury, but it also can contribute to secondary 

brain damage. Secondary injury also might result from 

other systemic events related to multiple injuries in other 

organs or body parts. 

TBI can appear as a focal (localized) or diffuse 

(widespread) injury. Some persons exhibit both. A focal 

injury results when bleeding, bruising, or a penetrating 

injury is isolated to a portion of the brain. A diffuse brain 

injury occurs when brain tissue suffers more widespread 

damage, often resulting from acceleration and deceleration 

forces. Impact of the head against another object can cause 

focal brain injury under the skull at the site of impact and 

at a site on the opposite side of the head (Adams, Mitchell, 

Graham, and Doyle, 1977). The most common form of 

TBI is caused by a combination of impact and acceleration/

deceleration forces, such as those occurring in high-speed 

motor vehicle crashes (Kotapka et al., 1991; Adams, 

Graham, Murray, and Scott, 1982). 

Certain regions of the brain are particularly vulnerable to 

the external forces that cause TBI (Bigler, 2007). External 

forces that initiate brain movement can stretch and disrupt 

the integrity of brain tissue and cause the brain to impact 

boney protuberances within the skull. The frontotemporal 

lobes of the brain are particularly susceptible to this 

phenomenon because these regions are situated above 

boney surfaces in the skull where brain tissue can be easily 

injured with impact or forceful movement. For this reason 

it has been hypothesized that the susceptibility of the 

frontotemporal lobes are the basis for the cognitive and 

behavioral symptoms commonly experienced after a TBI 

(Bigler, 2007). 

Table 1. Glasgow Coma Scal

Ability Score

Eye opening (E)

Spontaneous 4

To voice 3 

To pain 2

None 1

Motor response (M)

Normal 6

Localized to pain (purposeful movement toward site 

of pain) 5

Withdraws to pain 4

Abnormal flexion to pain 

(an abnormal posture that can include rigidity, 

clenched fists, legs held straight out, and arms bent 

inward toward the body with the wrists and fingers 

bent and held on the chest)

3 

Abnormal extension to pain (an abnormal posture 

that can include rigidity, arms and legs held straight 

out, toes pointed downward, head and neck arched 

backwards)

2

None 1

Verbal response (V)

Normal conversation 5

Disoriented conversation 4

Words, but not coherent 3

No words, only sounds 2

None 1

Score: Eye score (E) + Motor score (M) + Verbal score (V)= 

3 to 15

Teasdale and Jennett, 1974
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 17

Injury Severity Classification of TBI

Although several injury indicators exist for the 

classification of TBI, the Glasgow Coma Scale (GCS) is 

the most widely used (Malec et al., 2007; Teasdale and 

Jennett, 1974). The GCS is a neurologic scale consisting of 

three components: eye opening, verbal response, and motor 

response. The component scores are added to create an 

overall score to determine a patient’s level of consciousness 

(Table 1). The GCS was originally developed in 1974 to 

assess coma and other impaired levels of consciousness 

based on observed clinical signs and symptoms (Teasdale 

and Jennett, 1974), but was later adopted to assess TBI 

severity ( Jagoda et al., 2008). However, the GCS has some 

limitations. Factors not necessarily related to the injury 

might affect the GCS score and lead to misclassification 

of TBI severity. Some of these include factors that can 

independently alter consciousness such as medical sedation, 

alcohol or drug intoxication, and organ system failure. 

TBI severity can be misclassified when the GCS is used 

alone. Because of this, additional criteria are used in clinical 

practice and research (Boyd, Tolson, and Copes, 1987; 

Cooke, McNicholl, and Byrnes, 1995; Stein, 2001). 

These include duration of altered mental state or loss of 

consciousness and duration of post-traumatic amnesia. 

Imaging techniques, such as computed tomography (CT) 

scans, also can be used to identify structural damage that 

might contribute to the assessment of injury severity. In 

research studies, the Abbreviated Injury Scale (AIS) score 

for the head and neck region (Baker, et al, 1974; Brasure, 

et al., 2012) can be used to classify TBI. The AIS ranks 

injuries on a six-point scale based on mortality risk, with “1” 

indicating minor injury and “6” indicating a non-survivable 

injury. The relationship of these measures to classification of 

TBI severity as mild, moderate, or severe, is shown in Table 

2. However, as with the GCS, each of the severity criteria 

has limitations and might not be an accurate predictor of 

TBI severity and outcome when used alone.

Table 2. Criteria used to classify TBI severit

TBI SEVERITY

Criteria Mild Moderate Severe

Structural 

imaging Normal Normal or abnormal

Normal or 

abnormal

Loss of 

consciousness <30 minutes 30 minutes to 24 hours >24 hours

Post traumatic 

amnesia 0–1 day >1 and <7 

days >7 days

Glasgow Coma 

Scale score 

(best available 

score in 

24 hours)

13–15 9–12 3–8

Abbreviated 

Injury Scale 

score: Head

1–2 3 4–6

Source: Brasure et al., 2012
18 CENTERS FOR DISEASE CONTROL AND PREVENTIO

Health and Other Effects of TBI

TBIs can lead to a spectrum of secondary conditions 

that might result in long-term impairment, functional 

limitation, disability, and reduced quality of life. Health 

effects associated with TBI can be broadly categorized 

into cognitive, behavioral/emotional, motor, and somatic 

symptoms (Riggio and Wong, 2009; Walker and Pickett, 

2007). Given the high frequency of frontal lobe injury, 

cognitive impairment is the hallmark injury of TBI; 

however, combinations of these health effects are frequently 

experienced. The evolution of secondary symptoms 

following TBI will vary across persons and is dependent 

on the injury location, injury severity, and medical history 

before the injury (McAllister and Arciniegas, 2002; 

Silver, McAllister, and Yudofsky, 2011). Although not 

an exhaustive list of potential TBI-related health effects, 

common cognitive, behavioral/emotional, motor, sensory, 

and somatic signs and symptoms associated with TBI are 

presented in Table 3.

Psychological and neurologic disorders also can develop 

following TBI, which also might contribute to varying 

degrees of long-term impairment, functional limitation, or 

disability. These include mood disorders, (e.g., depression), 

and post-traumatic epilepsy (Rosenthal, Christensen, 

and Ross, 1998; Hart, Brenner, Clark, Bogner, Novack, 

Chervoneva, Nkase-Richardson, and Arango-Lasprilla, 

2011; Lowenstein, 2009; Agrawal, Timothy, Pandit, and 

Manju, 2006). Post-traumatic stress disorder (PTSD) 

and dementia also are conditions of concern for persons 

affected by TBI. Considerable gaps in understanding exist 

with regard to the overlap and specific relations among TBI 

and these conditions (Bryant, 2011; Wang, Lin, Sung, Wu, 

Hung, Wang, Huang, Lu, Chen and Tsai, 2012). 

Adverse health effects also affect work-related behaviors, 

and these include difficulties with social interactions, 

organizational obstacles caused by an acquired disability, 

health and safety concerns, and challenges with work 

attitude, skills, behavior, and performance (Tyerman, 

2012). For working-aged adults, the return to work, school, 

and other pre-injury activities after TBI are key elements 

for life satisfaction. Failure to achieve a self-perceived 

productive role in society after TBI comes at personal and 

economic cost to injured persons, their families, and society 

(Selassie et al., 2008). However, gainful employment for a 

person affected by TBI has positively influenced outcomes 

and contributed to self-reported life satisfaction (Corrigan, 

Bogner, Mysiw, Clinchot, and Fugate, 2001). 

Table 3. Health effects associated with TB

Category Description

Cognitive Deficits in: attention; learning and memory; executive functions like planning and decision-making; language 

and communication; reaction time; reasoning and judgment

Behavioral/ Emotional Delusions; hallucinations; severe mood disturbance; sustained irrational behavior; agitation; aggression; 

confusion; impulsivity; social inappropriateness 

Motor Changes in muscle tone; paralysis; impaired coordination; changes in balance, or 

trouble walking

Sensory Changes in vision and hearing; sensitivity to light

Somatic signs and symptoms Headache; fatigue; sleep disturbance; dizziness; chronic pain

Sources: Anstey et al., 2004; Asikainen, Kaste, and Sarna, 1999; Clinchot, Bogner, Mysiw, Fugate, and Corrigan, 1998; Dikmen, Machamer, 

Fann, and Temkin, 2010; Granacher, 2005; Katz, White, Alexander, and Klein, 2004; Meares et al., 2011; Orff, Ayalon, and Drummond, 2009; 

Riemann and Guskiewicz, 2000; Riggio and Wong, 2009; Rogers and Read, 2007; Schmidt, Register-Mihalik, Mihalik, Kerr, and Guskiewicz, 

2012; Silver et al., 2011; Williams, Morris, Schache, and McCrory, 2009; Ziino and Ponsford, 2006; Nampiaparampi, 2008. 
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 19

Burden of TBI

Incidence and Epidemiology 

Each year, approximately 30 million injury-related 

emergency department (ED) visits, hospitalizations, 

and deaths occur in the United States. Of the injury 

hospitalizations, approximately 16% included TBI as a 

primary or secondary diagnosis. Of the injury deaths, 

approximately one-third included a TBI as a direct or 

underlying cause of death. In 2010, CDC estimated that 

TBIs accounted for approximately 2.5 million ED visits, 

hospitalizations, and deaths in the United States, either 

as an isolated injury or in combination with other injuries. 

Of these persons, approximately 87% (2,213,826) were 

treated in and released from EDs, another 11% (283,630) 

were hospitalized and discharged, and approximately 

2% (52,844) died. These figures, however, underestimate 

the occurrence of TBIs, as they do not account for those 

persons who did not receive medical care, had outpatient 

or office-based visits, or those who received care at a federal 

facility (i.e., persons serving in the U.S. military or seeking 

care at a Veterans Affairs hospital) (Faul et al., 2010). 

Department of Defense data revealed that from 2000 

through 2011 235,046 service members (or 4.2% of the 

5,603,720 who served in the Army, Air Force, Navy, and 

Marine Corps) were diagnosed with a TBI (CDC, NIH, 

DoD, and VA Leadership Panel, 2013). 

In the United States, children aged 0–4 years, adolescents 

aged 15–19 years, and older adults aged ≥75 years are 

the groups most likely to have a TBI-related ED visit or 

hospitalization (Faul et al., 2010). Adults aged ≥75 years 

have the highest rates of TBI-related hospitalizations and 

deaths among all age groups. Overall, males account for 

approximately 59% of all reported TBI-related medical 

visits in the United States (Faul et al., 2010). 

As shown in Table 4, during 2002—2010, the leading 

causes of TBI-related ED visits were falls, being struck 

by or against an object, and motor-vehicle traffic crashes. 

The leading causes of TBI-related hospitalizations were 

falls, motor-vehicle traffic incidents, and assaults. For 

TBI-related deaths, the leading causes were motor-vehicle 

traffic incidents, suicides, and falls (Coronado et al., 

2012). The proportion of TBIs occurring during sports 

and recreation-related activities is undetermined because 

of limitations of the data source. However, according to 

the National Electronic Injury Surveillance System – All 

Injury Program, during 2001–2009 (CDC, 2011) the 

activities associated with the greatest estimated number of 

TBI-related ED visits were bicycling, football, playground 

activities, basketball, and soccer among persons younger 

than 19 years. 

Incidence of TBI-related Disability

In the United States availability of data related to the 

incidence of TBI-related disability is limited. The few 

national-level estimates that have been reported are 

based on extrapolations of state-level data from South 

Carolina and Colorado. These extrapolations suggest that 

3.2 million–5.3 million (Selassie et al., 2008; Zaloshnja 

et al., 2008; Thurman et al., 1999) persons were living with 

a TBI-related disability at the time of those studies. 

Table 4. Estimated average annual numbers

of traumatic brain injury-related emergency 

department (ED) visits, hospitalizations, and 

deaths, by external cause, United States, 

2002–2010

Mechanism 

of injury ED visits Hospitalizations Deaths

Falls 658,668 66,291 10,944

Struck by or 

against an object

304,797 6,808 372

Motor vehicle 

traffic

232,240 53,391 14,795

Assault/Homicide 179,408 15,032 5,665

Self-inflicted/

Suicide

* * 14,713

Other 122,667 25,478 4,990

Unknown 97,018 113,172 0

*Estimate not reported because of small numbers
20 CENTERS FOR DISEASE CONTROL AND PREVENTIO

Trends in Traumatic Brain Injury

Figure 1 illustrates the annual age-adjusted rates per 

100,000 persons in the United States for TBI-related 

ED visits, hospitalizations, and deaths. Since 2007, for 

every 100,000 persons in the United States the rate of 

total TBI-related ED visits, hospitalizations, and deaths 

have increased 45%, from 566.7 to 823.7. This increase 

in TBI-related medical encounters is primarily driven by 

an accompanying increase in the rate of TBI-related ED 

visits, which have increased 56%, from 457.5 in 2007 to 

715.7 in 2010. In contrast, TBI-related hospitalizations 

and deaths have not increased similarly. Specifically, the 

rate of TBI-related hospitalizations has been relatively 

stable since 2007, as evidenced by an identical rate of 

TBI-related hospitalizations in both 2007 and 2010 (91.7 

per 100,000 persons). TBI-related death rates decreased 

from 18.2 to 17.1 per 100,000 persons from 2007 to 

2010. The reason(s) for an increase in ED visits and a 

decrease in TBI-related deaths is not known. However, 

one plausible explanation is that a continued reduction in 

motor-vehicle crashes (the leading mechanism of TBIrelated death) has reduced the TBI-related death rate. The 

increase in TBI-related ED visits might be related to an 

increased awareness about TBI resulting in more persons 

seeking care. Awareness of the health risks from TBI have 

been driven by increased media coverage of sports-related 

concussions, state-level legislation that requires coaches to 

receive training related to recognition and management of 

sports-related concussions, and public education campaigns 

(e.g., CDC’s HEADS UP) targeted to athletes, parents, 

coaches, health care providers, and educators. Lending 

support to the role of sports-related concussions affecting 

the rate of TBI-related ED visits, one study determined 

that during 2001–2009, the number of sports and 

recreation–related ED visits for TBI among persons aged 

≤19 years increased 62% (CDC, 2011). 

Figure 1. Annual age-adjusted rates of TBI-related Emergency Department (ED) visits, hospitalizations,

and deaths—United States, 2001–2010
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 21

Unique Considerations for Specific Populations

TBI can pose challenges for all persons, regardless of age, 

sex, geography, military status, or other distinguishing 

characteristics. Although the risk factors, health effects, 

and long-term implications of TBI vary for each person, 

some persons require special considerations (e.g., pediatric 

and older adult age groups, residents of rural geographical 

areas, military service members and veterans, and 

incarcerated populations).

Children (Aged 0–19 Years )

Approximately 145,000 children and adolescents aged 

0–19 years are estimated to be living with substantial 

and long-lasting limitations in social, behavioral, physical, 

or cognitive functioning following a TBI (Zaloshnja, et 

al., 2008). However, these numbers likely underestimate 

the true consequences of pediatric TBI, given the underreporting of mild TBI (mTBI) or concussion, and abusive 

head trauma (Theodore et al., 2005). 

A TBI experienced by a child can contribute to physical 

impairments, lowered cognitive and academic skills relative 

to developmental expectations, and deficits in behavior, 

socialization, and adaptive functioning, depending on the 

presence of factors that influence outcomes (see Factors 

Influencing Outcomes) (Anderson et al., 2006; Yeates et al., 

2004; Yeates and Taylor, 2006). Some studies suggest that 

even children with mild injuries are at risk for disability 

(Rivara, et al., 2012). Children with a TBI can experience 

specific impairments in language, memory, problem-solving, 

perceptual-motor skills, attention, and executive function 

(Anderson et al., 2006; Gerrard-Morris et al., 2010; Taylor 

et al., 2008). 

In pediatric populations, some effects of a TBI may 

not be present initially, but can emerge later in a child’s 

development. This delay of onset can manifest itself in 

later academic failure, chronic behavior problems, social 

isolation, and difficulty with employment, relationships, 

and, in some cases, difficulty with the law (Ewing-Cobbs 

et al., 2004 Gerrard-Morris et al., 2010; Hendryx and 

Verduyn, 1995; Williams, Cordan, Mewse, Tonks, 

and Burgess, 2010). Unlike other injuries with chronic 

consequences, the physical effects of TBI in children are 

often difficult to recognize. For this reason, common 

behavioral manifestations of TBI in children and 

adolescents, such as lack of inhibition, difficulty reading 

social cues, and emotional lability, might be mistakenly 

attributed to other causes ranging from lack of motivation 

and laziness to bad parenting (Wade et al., 2010). 

Older Adults (≥75 Years)

Current studies estimate that approximately 775,000 older 

adults live with long-term disability associated with TBI 

(Zaloshnja et al., 2008). The TBI sequelae of older adults 

are often attributed to the aging process rather than an 

injury, preventing affected seniors from being accurately 

diagnosed and treated. Older adults affected by TBI have 

a higher risk for mortality (Thompson, McCormick, and 

Kagan, 2006) and worse functional outcomes following 

injury than younger patients with similar injuries, 

regardless of initial TBI severity (Cifu et al., 1996; Susman 

et al., 2002). The societal and medical-care costs of TBI 

also are more extensive for older adults than younger 

patients. When compared with younger patients, older 

adults had longer hospital stays and slower rates of 

functional improvement during inpatient rehabilitation 

(Cifu et al., 1996; Miller and Pentland, 1989). Preexisting 

medical conditions, (Mosenthal et al., 2004), also were 

found to increase the length of stay among older adults in 

outpatient rehabilitation (Yu and Richmond, 2005). 

Rural Geographical Residents

Data indicate that the prevalence of TBI-related disability 

in rural geographical areas is higher than urban and 

suburban areas (24% compared with 15% and 14%, 

respectively) (Kaye, 1997). Persons affected by TBI in 

rural areas are less likely to have access to specialized 

trauma care and rehabilitation professionals ( Johnstone, 

Nossaman, Schopp, Holmquist, and Rupright, 2002; 

Murphy, 2004). Fewer resources exist in rural communities 

to support independent living after a TBI, such as longterm rehabilitation facilities or community-based services 

(Sample, Tomter, and Johns, 2007).

Transportation limitations further restrict service delivery 

in rural communities. Rural residents travel two to three 

times further for specialty care, attend fewer medical visits 

even when community resources are available, and have less 

access to medical specialists (Chan, Hart, and Goodman, 

2006; Sample et al., 2007). Primary care physicians are 

more likely to be the single source of care of persons with 

TBI-related disability in rural areas, and are less likely to 
22 CENTERS FOR DISEASE CONTROL AND PREVENTIO

have received advanced training in the management of TBI. 

(Lishner, Richardson, Levine, and Patrick, 1996). Finally, 

persons affected by TBI who are enrolled in vocational 

rehabilitation services in rural geographical areas are more 

likely to discontinue services and have considerably worse 

employment outcomes when compared with vocational 

rehabilitation clients in urban areas (7% compared with 

24%, respectively) ( Johnstone, Reid-Arndt, Franklin, and 

Harper, 2006).

Military Service Members and Veterans 

Since the beginning of Operation Enduring Freedom 

(OEF) (Afghanistan) and Operation Iraqi Freedom 

(OIF) in the early 2000s, public health and health care 

communities have become aware of increased rates 

of TBI among active duty U.S. military personnel. In 

response to these public health and medical concerns, 

Congress passed the Traumatic Brain Injury Act of 2008. 

The Act required CDC and NIH, in consultation with 

DoD and VA, to determine how best to improve the 

collection and dissemination of information related to 

the incidence and prevalence of TBI among persons who 

were formerly in the military. In addition, the goal was to 

provide recommendations for CDC, NIH, DoD, and VA 

collaboration on the development and improvement of TBI 

diagnostic tools and treatments. (For more information 

about TBI specifically related to military populations, 

please see CDC’s Report to Congress on Traumatic Brain 

Injury in the United States: Understanding the Public Health 

Problem among Current and Former Military Personnel 

(http://www.cdc.gov/traumaticbraininjury/pubs/

congress_military.html).

Military service members and veterans from recent 

conflicts and combat are a population of special concern. 

However, of all new cases of TBI among military 

personnel, approximately 80% occur in non-deployed 

settings. In addition to motor-vehicle crashes, falls, sportsand recreation-related injuries, and assaults—military 

members also might sustain TBIs during training activities 

(DVBIC, 2013) (Reference for military external causes of 

injury: MSMR, 2013).

The combat situations that cause TBI in conflict zones 

might contribute to other problems (e.g., post-traumatic 

stress disorder [PTSD]). Recent research suggests that 

a history of mild TBI might place persons at increased 

risk for developing PTSD even after adjusting for type 

of injury (Bryant et al., 2010). Moreover, those with both 

PTSD and mild TBI are at greater risk for various postconcussive symptoms following injury than those with 

either PTSD or mild TBI alone (Brenner et al., 2010). 

PTSD, pain conditions, mood disorders, and substanceuse or misuse can yield symptoms similar to those of mild 

TBI (e.g., difficulty sleeping) making differential diagnoses 

challenging. Growing awareness of the problems facing 

service members and veterans has illuminated the need 

for rehabilitation research that is focused on evidencebased interventions for mild TBI, TBI complicated by 

psychological conditions like PTSD, and best practices to 

facilitate the transition from military to civilian life. 

Incarcerated Populations

Incarcerated populations are another population heavily 

affected by TBI. It is estimated that the prevalence of TBI 

in imprisoned populations is 60.3% (Shiroma, Ferguson, 

and Pickelsimer, 2012). This suggests that in many cases 

the illegal acts leading to incarceration, as well as noncompliant prison behaviors and subsequent recidivism, may 

be at least been partially influenced by the effects of a TBI. 

In addition, data from a statewide sample of prisoners in 

South Carolina indicated that approximately 65% of men 

and 72% of women reported a TBI (Ferguson, Pickelsimer, 

Corrigan, Bogner, and Wald, 2012). However, how and 

when incarcerated populations experienced a TBI or the 

circumstances surrounding the injury remains unclear. 
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 23

Gaps in Determining the Incidence of TBI

CDC provides annual updates on the national incidence 

of TBI. However, the limitations of the available TBI data 

create barriers in fully describing the incidence of TBI 

in the United States. National estimates of TBI in the 

United States are based on health care administrative data 

describing the number of TBI-related hospitalizations, ED 

visits, and deaths. Consequently, persons who do not seek 

care for a TBI or seek care at a physician’s office, urgent care 

center, or other non-emergency outpatient department are 

not included in these estimates. 

Data sources that have been used to capture TBIs 

diagnosed during these health care encounters have not had 

sufficient sample sizes to produce reliable yearly estimates. 

Adding to the problem is the likelihood of multiple visits 

from the same patient for the same injury, making it 

difficult to generate an accurate count of TBI incidence. 

In addition, surveillance is not in place to determine how 

many persons might have had a TBI but did not seek 

medical care. As a result, TBI incidence estimates are likely 

undercounted. Another gap involves a lack of uniform 

race and ethnicity data in TBI data-systems, which makes 

examining trends in TBI incidence by race/ethnicity 

difficult. Finally, although CDC has funded 20 states to 

produce state-level TBI incidence estimates, TBI incidence 

data is limited in states that have not been funded. 

Until recently, trends in the national incidence of TBI by 

demographic subgroups and mechanism of injury have 

been difficult to assess. Data sources used to examine 

TBI-related hospitalizations and ED visits have not had 

sufficient sample sizes to produce single-year estimates by 

demographic subgroups and mechanisms of injury. As a 

result, multiple years of observations had to be aggregated 

to examine the overall incidence of TBI in subpopulations. 

CDC has recently developed a new strategy to examine 

TBI-related medical encounters by using data from the 

Healthcare Cost and Utilization Project (HCUP). These 

data will enable CDC to generate single-year estimates of 

TBI incidence by demographic subgroup. These HCUP 

data sources are more widely sampled than the previously 

utilized data sources and allow for estimates of population 

subgroups without aggregating multiple years of data. This 

step forward will allow CDC to provide a more fine-grained 

understanding of how TBI incidence varies over time. 

Gaps exist in the surveillance of TBIs that occur in in 

sports-and recreation-related activities. TBI-related 

health care visits are defined by diagnostic codes from the 

International Classification of Diseases, Ninth Revision, 

Clinical Modification (ICD-9-CM, for hospitalizations 

and ED visits) and Tenth Revision (ICD-10, for deaths). 

And yet, little information is available that describes the 

mechanism of injury - particularly information related to 

whether the injury occurred during a sport or recreational 

activity and the particular sport or recreational activity 

that was being engaged in at the time of the injury. Persons 

who experience a TBI while participating in sports and 

recreational activities, and who seek care at an ED, are 

included in the overall incidence estimates. However, they 

are included in broad external cause-of-injury categories, 

such as falls or being struck by or against an object—rather 

than being identified as having been injured in a sports or 

recreational activity. Using current data systems it is not 

possible to describe sports- and recreation-related TBIs as 

a separate category for those who are hospitalized or die as 

the result of sports- or recreation-related TBI. 

Current surveillance systems that can capture sports- and 

recreation-related concussions are based on data collected 

during ED visits or injuries experienced in organized high 

school or college sports leagues. Consequently, these systems 

do not capture the full range of sports- and recreationrelated concussions. Specifically, these systems miss out on 

sports- and recreation-related concussions that do not result 

in an ED visit and/or concussions experienced outside of 

organized sports at the high school level or higher. Also, 

these systems do not routinely collect a person’s concussion 

history, use of personal protective equipment such as a 

helmet, and other circumstances of an injury.

.
24 CENTERS FOR DISEASE CONTROL AND PREVENTIO

Gaps in Determining the Prevalence of Persons with TBI-related Disability

Currently, ongoing surveillance of TBI-related disability 

does not exist. The only nationally representative estimates 

of TBI-related disability are based on extrapolations of 

one-time state-level estimates of lifetime TBI-related 

disability (Selassie et al., 2008; Zaoshnja et al., 2008). The 

limited data available result in the following limitations: 

no true national-level estimates; no 12-month prevalence 

estimate of TBI-related disability; an inability to examine 

state-level variation; no recent estimates; an inability to 

monitor trends; and an inability to examine variation 

in TBI-related disability by important demographic 

subgroups such as race/ethnicity or military status.
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 25

Recommendations

Recommendations to fill gaps in understanding the epidemiology and consequences of TBI include the following:

➤ Improve TBI incidence and prevalence estimates to include persons with TBIs who 

are treated in non-hospital settings and those with TBIs who are not receiving 

medical care. Develop or identify sources of non-hospital TBI incidence data, 

such as data from physician offices and other sources of outpatient medical 

encounters, to improve estimates. Similarly, develop or identify data sources that 

capture information from persons who might have experienced a TBI but did not 

seek medical care for their injury. 

➤ Generate state-specific TBI estimates. Collect and compile health care 

administrative data in all states to quantify and examine state-level variations in 

TBI burden. In addition, state-level TBI estimates can be used to inform decisions 

related to the allocation of preventive and rehabilitative services that are made at 

the state level.

➤ Better understand injury mechanisms and their effect on sub-populations. Examine 

trends in TBI incidence by injury mechanism and within population subgroups 

(e.g., children, older adults, and others) by using data systems such as HCUP. This 

practice can help target prevention resources to populations at greatest risk for TBI.

➤ Enhance monitoring of sports and recreation concussions. Develop and implement 

a concussion surveillance system that captures the full range of sports- and 

recreation-related concussions. Current surveillance systems only capture 

emergency department visits or injuries experienced in organized high school 

sports, collegiate athletics, and some professional leagues. 

➤ Produce population-level estimates of TBI-related disability. Add TBI-related disability 

to large, existing national health surveys, and analyze large-scale claims or 

administrative datasets to produce population-level estimates. 
26 CENTERS FOR DISEASE CONTROL AND PREVENTIO
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 27

SECTION II

Effectiveness of TBI Outcome Measures 

Importance of Outcome Measurement 

The range of short and long term effects from a TBI is varied. Beyond TBI mortality, various elements related to outcomes 

must be characterized: physical, neuropsychological, psychiatric, behavioral, functional, and quality-of-life outcomes. The 

primary goal for TBI rehabilitation is to assist the injured person in achieving an optimal level of functioning. Outcome 

measurement helps us assess the status of a person’s recovery and rehabilitation. This information can be used to monitor the 

progress of treatment in the clinical setting and to demonstrate treatment progress to a third-party payer. More broadly, these 

outcomes undergird research on the effectiveness of TBI rehabilitation and better inform future clinical interventions. 

The Common Data Elements Project

Recently, the Common Data Elements (CDE) Project served to better classify the key domains for TBI rehabilitation outcome 

measurement. The CDE Project was a joint effort of the National Institute of Neurological Disorders and Stroke (NINDS) 

and several co-sponsoring federal agencies. The goal of the CDE Project was to develop data collection standards for clinical 

research. The work was divided into workgroups comprised of specialists focused on problems related to the quality of TBI 

research data, including workgroups focused on PTSD, biomarkers, neuroimaging, and outcomes (Wilde et al., 2010). 

The TBI CDE Outcomes Workgroup was convened to identify the core elements and a common set of outcome measures 

needed for TBI rehabilitation research (Wilde et al., 2010). The workgroup examined multiple outcomes potentially affected by 

TBI and identified measures that assess the range of short- and long-term outcomes for all severities of TBI (Wilde et al., 2010). 

Descriptions of the outcome domains identified by the TBI CDE Outcomes Workgroup are provided in Table 5. 
28 CENTERS FOR DISEASE CONTROL AND PREVENTIO

Table 5. Outcome domains and descriptions for TBI common data element

Domain name Domain description and relevance in TBI

Global outcome Global outcome measures summarize the overall impact of TBI and incorporate functional status, 

independence, and role participation

Recovery of consciousness Duration of coma, level of consciousness, and rate of recovery contribute significantly to functional 

outcome and play a key role in treatment and disposition planning.

Neuropsychological impairment Objective measures of neuropsychological functions such as attention, memory, and executive 

function are very sensitive to the effects of TBI, and often affect everyday activities and social role 

participation.

Psychological status Psychological issues associated with TBI that affect outcomes include adjustment problems, 

personality changes (e.g., impulsivity), or mood disturbances. In addition, substance use disorde

are prevalent among persons with TBI and can have a substantial impact on long-term outcomes

TBI-related symptoms TBI-related symptoms include somatic (e.g., headaches, visual disturbances), cognitive (e.

attention and memory difficulties) and emotional (e.g., irritability) symptom.  They are common

reported after TBI or concussion and may persist in some cases at all levels of TBI severity

Behavioral function Behavioral dysfunction (e.g., aggression, childlike behavior) is commonly reported following TB

and may contribute to difficulties in returning to work or school, personal relationships, and social 

functioning

Cognitive activity limitations Cognitive activity measures describe the impact of neuropsychological impairments on cognitively 

loaded real-world tasks such as instrumental activities of daily living, functional communication, and 

health and safety-related behaviors

Physical function Individuals with TBI (particularly severe TBI) may manifest difficulties in physical or neurological 

functioning, including cranial or peripheral nerve damage, impairment in motor functioning, strength 

and coordination, or impairment in sensation. These impairments may contribute to difficulties in

performing day-to-day activities safely and independently

Social role participation Participation is defined by the World Health Organization (WHO) as “involvement in life situations” 

(World Health Organization [WHO], 2001) and commonly includes engagement in endeavors within 

one’s community. TBI affects many areas of participation including work or productive activity,

recreation and leisure pursuits, and social and family role function

Perceived generic and diseasespecific health-related quality 

of life

TBI may create significant limitations in multiple areas of functioning and well-being, often reducing 

perceived quality of life with regard to multiple generic and disease-specific dimensions

Health-economic measures Health-economic measures to assess the cost benefit, e.g., the most cost-effective therapeuti

procedure in terms of cost per Quality Adjusted Life Year.

Patient-reported outcomes (future 

multidimensional tools)

No single measure to date can adequately capture the multiplicity of difficulties that individuals with 

TBI may face. This domain includes emerging large-scale measurement tools for patient reported

outcomes across several domains for generic medical populations, neurological compromise, and 

TBI-related complaints
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 29

The TBI Outcomes Workgroup assessed the properties 

of each recommended outcome measure to account for 

its relevance in the identified domains. The workgroup 

recommended specific measures based on evidence 

demonstrating the reliability, validity, and other relevant 

properties. The effectiveness of the recommended measures 

is informed by the following criteria (Wilde et al., 2010):

➤ Sufficient representation in 

the scientific literature and/or 

widespread use in the TBI clinical 

and research communities; 

➤ Evidence of adequacy, including 

construct validity, internal 

consistency, sensitivity to change, 

test-retest reliability, intra-/

inter-rater agreement; 

➤ Well-established normative data; 

➤ Applicability across a range of injury 

severity and functional levels; 

➤ Availability in the public domain; 

➤ Ease of administration; 

➤ Brevity. 

Each measure has strengths and limitations and their 

respective results must be interpreted accordingly. For 

example, the Disability Rating Scale (DRS) is a global 

outcome measure that can be used to track general 

functional changes over the course of recovery. It has been 

shown to predict employment fairly well, particularly 

for persons with moderate to severe TBI. However, 

the DRS is relatively insensitive to subtle neurological 

deficits that might only be noticed by the injured person. 

The development of CDEs provides researchers with 

standardized measures that are both reliable and valid. 

Although each of the measures also has been examined for 

sensitivity to change, expected changes from rehabilitation 

might be subtle and outcome measures might fail to 

identify clinically meaningful changes. This is noted 

above in the discussion of the DRS, but might also be 

true for other global outcome scales when not used with 

detailed assessments that can take hours to implement 

(Shukla, Devi, and Agrawal). As a result of these concerns, 

agencies involved in the development of the TBI NRAP 

(Department of Defense, Veteran Affairs, Health and 

Human Services and Education, 2013) included as one 

of its goals for immediate action: “Develop efficient, 

affordable, comprehensive, valid, and sensitive tools for 

assessing functional outcomes and quality of life over time” 

with the intent to “improve clinical assessment and enable 

measurement of treatment effectiveness specific to the 

TBI population”. 

A complete list of the recommended outcome measures 

and their individual properties has been published 

elsewhere (Wilde et al., 2010). 

TRACK-TBI Study

A multicenter study, Transforming Traumatic Brain Injury 

Research and Clinical Care (TRACK-TBI), funded 

by NIH-NINDS, sought to validate the feasibility of 

implementing a broad range of TBI-CDEs in a prospective 

observational study. Patients were recruited through four 

study sites, including three acute care sites (San Francisco 

General Hospital, University of Pittsburgh Medical 

Center, and University Medical Center Brackenridge in 

Austin, Texas) and a rehabilitation center (Mount Sinai 

Rehabilitation Center in New York City). Although this 

study concluded that the implementation of the TBI CDEs 

is feasible, TRACK-TBI researchers identified several gaps 

related to the outcome-related CDEs for adult TBI (Yue, et 

al., 2013). 

These gaps included the identification of a lack of validated 

outcome measures for TBI patients living with greater 

disability. In addition, while the TBI CDE Workgroup 

considered the availability of outcome measures validated 

among non-English speaking patients as a factor in 

recommending specific measures, TRACK-TBI found 

several measures that could not be administered to 

non-English speaking patients (Yue et al., 2013). The 

researchers recommended validating additional TBI CDE 

measures in languages other than English and including 

nonverbal memory tests, which can be useful irrespective 

of the language spoken by the patients (Yue et al., 2013). 

TRACK-TBI has been expanded and is now an ongoing 

study designed to establish more precise methods for TBI 

diagnosis and prognosis, improve outcome assessment, and 

compare the effectiveness and costs of tests, treatments, and 

services. Harmonized data collection with a parallel study 

funded by the European Union, Collaborative European 

Neurotrauma Effectiveness Research (CENTER-TBI) will 

add to its value. 
30 CENTERS FOR DISEASE CONTROL AND PREVENTIO

The Pediatric Common Data Elements Project

Although the effects of TBI cut across developmental stages, 

outcomes frequently manifest differently in a child than in an 

adult. For example, temper tantrums might be an indicator in 

children whereas belligerence might be an indicator in older 

adults. Consequently, measuring TBI outcomes in children 

can be difficult and presents an ongoing data challenge. 

Because children have a higher prevalence of executive 

function impairments (Anderson, Bigler, and Blotter, 

1995; Levin, Goldstein, Williams, and Eisenberg, 1991), 

determining whether results in clinical settings correspond 

to real life situations can be difficult (Eslinger, Biddle, and 

Grattan, 1997; Wilson, 1993). Therefore, a parallel attempt 

by the Pediatric CDE Workgroup was initiated to address 

the particular complexities involved in pediatric TBI 

research. Convened in 2011, the Pediatric CDE Workgroup 

was charged with modifying the adult TBI CDE research 

recommendations to include domains of functioning 

appropriate for children and adolescents. The workgroup 

emphasized the need for multiple outcome measurements 

across developmental stages—such as the transition from 

elementary school to middle school. Outcome measures 

spanning developmental age groups were given preference, 

and attention was given to assessing domains for infants 

and toddlers (McCauley et al., 2012). The pediatric CDEs 

include all of the domains identified as important for 

adults. In addition, the domains of academics, adaptive and 

daily living skills, family and environment, language and 

communication, and social cognition were included to reflect 

the importance of these domains for children’s every-day 

performance. Measures validated among infants and toddlers 

were identified as an additional domain. A complete list of 

these recommended outcome measures and their individual 

properties contributing to effectiveness has been published 

(McCauley et al., 2012). 

To better allow for comparisons across study types (e.g., 

epidemiology, long-term outcome research, and clinical 

trials), the adoption of the CDEs and the use of common 

outcomes measures is critical. Accumulating information 

from multiple studies can be used to improve the 

identification of persons at risk for persistent complications, 

for assessment of the short- and long-term effects of TBI, 

and management of persons from the stages of early care 

to long-term care and re-integration into society. The CDE 

workgroup’s recommendations for outcome studies for adults 

are highlighted in a series of published articles (Kaloupek et 

al., 2010; McCauley et al., 2012; Nash et al., 2010; Whyte, 

Vasterling, and Manley, 2010; Wilde et al., 2010). 

Table 6 contains the outcome domains unique to the 

pediatric population.

Table 6. Outcome domains and descriptions for TBI common data elements unique to pediatric

Domain Description

Academics Children with TBI have been found to have significant academic difficulties characterized by school failure and deficits in 

academic achievement, such as reading, math, and written language

Adaptive and daily 

living skills

Adaptive and daily life functioning consists of multiple domains and involves the ability to adapt to and manage one's 

surroundings to effectively function in home, school, and community life. This domain also includes children’s functional

activity and activity limitations.

Family and 

environment This domain includes moderators of outcome related to family and environment, as well as the consequences to family

Infant and toddler 

measures

Childhood and adolescence represent a wide range of developmental levels, and most pediatric measures are 

inappropriate for infants and toddlers. Therefore, limited special measures are included for this age rang

Language and 

communication

Deficits in language comprehension and expression and in speech articulation are common after TBI. Measures of

language use in context (pragmatics) are particularly sensitive to TBI effects

Social cognition Social cognition refers to the cognitive processes necessary for successful social interaction. A growing body of literature

has documented impairments in this domain after TBI, in some cases independent of other cognitive impairments

Source: McCauley et al., 2012
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 31

Factors Influencing Outcomes 

Recovery from TBI is influenced by classes of factors such 

as individual patient characteristics, social-environmental 

factors (e.g., family support systems), and barriers to 

rehabilitation access. The following sections outline some of 

these specific factors. 

Individual Characteristics

Individual characteristics, such as age and pre-injury 

functioning, can influence outcomes after TBI. These 

characteristics differentially influence outcomes based 

upon the severity of injury. For example, children who 

sustain a moderate-to-severe TBI before the age of 7 years 

have substantially worse short- and long-term outcomes 

than children who suffer a similar injury at an older age 

(Anderson, Bechara, Damasio, Tranel, and Damasio, 1999; 

Barnes, Dennis, and Wilkinson, 1999; Dennis, Wilkinson, 

Koski, and Humphreys, 1995; Ewing-Cobbs et al., 1997; 

Taylor and Alden, 1997; Verger et al., 2001). Behavioral 

changes and problems in adaptive functioning (i.e., coping 

skills) are the most persistent negative impacts of TBI 

in children (Anderson, Morse, Catroppa, Haritou, and 

Rosenfeld, 2004; Chapman et al., 2010; Fay et al., 2009; 

Schwartz et al., 2003). Older adults who sustain a TBI have 

lower survival rates and less favorable outcomes than those 

who sustain a TBI during young and middle adulthood 

(Frankel et al., 2006; Hukkelhoven et al., 2003).

 Pre-injury functioning also is related to various cognitive 

and behavioral outcomes. Persons with higher levels of preinjury cognitive functioning often preserve more functional 

capacity after TBI (Kesler, Adams, Blasey, and Bigler, 2003). 

This hypothesis suggests that a person might be able to use 

cognitive resources post-injury that were not needed or used 

before the injury. Finally, growing evidence of the role of 

genetic influences on outcome suggests that some alleles, or 

gene variants, might confer neuro-protection to some and 

vulnerability to others post-TBI (Zhou et al., 2008). 

Social-Environmental Factors

Social-environmental factors, such as socioeconomic 

status, caregiver and family functioning, and social support 

influence the effectiveness of rehabilitation treatments 

(Sander, Maestas, Sherer, Malec, and Nakase-Richardson, 

2012). Returning to participation in pre-injury social 

roles also is an important aspect of functioning for adults 

following a TBI. The ability to function in social roles is 

related to psychological and neurocognitive outcomes, but 

can also be influenced by other factors such as caregiver and 

family support, independent of TBI severity (Hart et al., 

2010). Social-environmental factors, such as the ability to 

live independently, maintain employment, or be involved in 

meaningful interpersonal relationships such as marriage, 

also can influence outcomes for persons affected by TBI 

(Sander and Struchen, 2011; Struchen et al., 2011). 

Family-level factors are critical social-environmental 

influences on outcomes for children following a TBI 

(Gerring and Wade, 2012). Family-level factors can include 

caregiver distress or depression, and deteriorating family 

functioning (Aitken et al., 2009; Wade, Carey, and Wolfe, 

2006a). Aspects of the home environment, such as parental 

responsiveness, negativity, and discipline practices, are 

linked to a child’s behavioral recovery (Wade et al., 2011a; 

Wade et al., 2002). Economic and social disadvantage 

have been associated with poor cognitive and academic 

outcomes following severe TBI (Taylor et al., 2002; Yeates, 

Taylor, Walz, Stancin, and Wade, 2010). Well-functioning 

caregivers and available financial and social supports 

contribute to better recovery and outcomes (Sander et 

al., 2002; Sander et al., 2009). In fact, family-centered 

interventions have been shown to be beneficial. Research 

has shown improved behavior of pediatric TBI patients and 

improved family functioning from this type of intervention 

(Wade et al., 2003; Wade, Walz, Carey, and Williams, 

2009). Studies also have demonstrated that cognitivebehavioral, problem-solving therapy can improve several 

pediatric outcomes, including executive function skills, 

behavior, and caregiver distress (Wade et al., 2006a, 2006b, 

2006d, 2010, 2011a; Wade, Michaud, and Brown, 2006c; 

Wade et al., 2011b). 

Access to Care after Hospitalization 

Persons with TBI who transition from acute injury 

care often are discharged home or admitted to one of 

various rehabilitation programs or facilities. Discharge 

disposition is influenced by both clinical and non-clinical 

factors. These factors frequently influence the type and 

quantity of rehabilitation care received, which can affect 

TBI outcomes. In some instances, adults with moderate 

to severe TBI are discharged home where the level and 

intensity of rehabilitation is not well defined (Cuthbert 

et al, 2011). For persons who do not immediately return 
32 CENTERS FOR DISEASE CONTROL AND PREVENTIO

home, the decision to discharge patients to inpatient 

rehabilitation (i.e., post-acute rehabilitation) or outpatient 

rehabilitation programs (i.e., sub-acute rehabilitation) is 

complex because the decision is frequently influenced by 

age, comorbidities, concurrent injuries, financial resources, 

and injury severity (Cuthbert et al, 2011). Outpatient 

rehabilitation programs are less intense, and are composed 

of fewer total hours of therapy, on average, compared with 

inpatient rehabilitation. 

Type of insurance coverage also is a predictor of discharge 

disposition (Buntin, 2007; Chan, Doctor, Temkin, 

MacLehose, Esselman, Bell & Dikmen, 2001; Cuthbert, 

Corrigan, Harrison-Felix, Coranado, Dikers, Heinneman 

& Whiteneck, 2011). For example, the Centers for 

Medicare & Medicaid Services (CMS) established specific 

criteria in regulation for inpatient rehabilitation admission 

in order to fulfill statutory coverage requirements that 

inpatient rehabilitation facility claims are for reasonable 

and necessary services. A patient’s condition must 

require active and ongoing therapy by at least three 

separate disciplines, and the patient must be capable of 

participating in at least 3 hours of therapy, 5 days per week 

or 15 hours during a 7-day period (Centers for Medicare 

& Medicaid Services, 2012). In addition, a patient must 

also be reasonably expected to actively participate in, and 

benefit significantly from, the intensive rehabilitation 

therapy program. Further, face-to-face supervision by 

a rehabilitation physician is required at least 3 days per 

week, and an intensive and coordinated interdisciplinary 

team approach to the delivery of rehabilitative care is 

also required. Patients who do not meet these criteria 

are discharged home or to sub-acute rehabilitation. 

Also, research suggests that patients with Medicare are 

more likely to be discharged to inpatient or outpatient 

rehabilitation (vs. home) compared with patients who 

pay out-of-pocket (Cuthbert et al., 2011). Outcomes 

for persons with TBI can be influenced by any of these 

external factors regardless of injury severity. Additional 

research is required to understand predictors of discharge 

disposition for persons with moderate-to-severe TBI and 

the subsequent bearing on outcomes.
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 33

Gaps in TBI Outcome Measurement

Outcome measurement plays a key role in identifying 

effective interventions. Research demonstrating 

effectiveness can then guide the targeting of interventions 

and the allocation of resources for persons with TBI. 

Outcome measurement also plays a key role in clinical 

rehabilitation settings, both as a way to monitor the 

progress of individual patients and as an indicator to 

third-party payers that a patient is making progress. 

Given the important functions of outcome measurement, 

the quality of outcome measures—validity, reliability, 

and sensitivity—is of paramount importance. These 

properties describe a measure’s ability to detect real 

changes in a particular outcome domain. Measures that are 

valid, reliable, and sensitive can be trusted to produce an 

accurate and reproducible assessment of the effects of an 

intervention and can help avoid inaccurate interpretations 

of intervention effectiveness. The potential for missing the 

identification of promising practices or the promotion of an 

ineffective intervention (Bagiella et al., 2010) can occur in 

the absence of validated measures.

The recent work conducted by the CDE TBI Outcomes 

Workgroup represents a step forward in identifying the key 

domains of outcome measurement and the identification 

of valid, reliable, and sensitive measures within those 

domains. By identifying outcome domains and outcome 

measures, based on criteria that support their effectiveness 

for use in research, the CDE TBI Outcomes Workgroup 

sought to bring consistency to outcomes measurement 

that will improve the quality and comparability of TBI 

outcomes research. 

However, a number of challenges are not adequately 

addressed by the recommended outcome measures 

(Wilde et al., 2010). For example, some measures require 

self-report. This can be problematic for persons with 

TBI who have cognitive and other deficits that impede 

communication. In these cases, a proxy might be used but 

more research is needed to determine the validity of proxy 

reports. Additionally, more representation of vocational 

and developmental outcome measures is needed. Also, 

some outcome measures have only been validated in limited 
34 CENTERS FOR DISEASE CONTROL AND PREVENTIO

populations (e.g., pediatric vs. adult, moderate/severe vs. 

mild) and some have been validated primarily outside of 

the TBI context (e.g., attention deficit hyperactive disorder 

[ADHD], stroke). Lastly, standard measures are still 

needed to account for various outcomes that are important 

for employment, community participation, and childhood 

development after a TBI. 

There has been a recent trend toward examining patientcentered outcomes based on the provision of feedback by 

patients and their care-givers related to treatment outcome. 

This has been helpful in ensuring that rehabilitation 

progress translates to improvements in the day-to-day life 

of patients. However, more studies are needed to validate 

patient-centered outcome measures. 

The efforts of the CDE TBI Outcomes Workgroup 

primarily addressed the need for a common set of outcome 

measures for research. However, administration of some 

CDE recommended outcome measures might not be 

feasible in clinical practice settings. For example, social 

role participation can only be assessed following inpatient 

rehabilitation discharge when the affected persons attempt 

to re-engage with their community. 

Most clinical assessments measure global outcome domains 

during inpatient rehabilitation. This is in contrast to 

individual specialties that might use discipline-specific 

indicators of therapeutic progress that do not have a 

comparable level of research support. Although the 

CDE TBI Outcomes Workgroup has made progress 

in identifying key outcome domains and valid outcome 

measures within the research context, a similar need exists 

for agreement regarding the measurement of outcomes in 

the clinical context. This will aid in comparing outcomes 

across clinical settings and improving the utility of clinical 

data for outcomes research. 

The TBI CDE Workgroup also identified several measures 

within each domain that have the potential to surpass the 

currently recommended measures. However, the measures 

identified did not have a comparable level of research 

support and were identified as promising. The measures 

identified as promising are good candidates for future 

research that could help improve current practices.

The TRACK-TBI study examined the feasibility of 

administering a broad range of TBI CDEs for adults, but 

no such large-scale effort has been made for the pediatric 

TBI population. Pediatric CDEs assess a broader range 

of outcomes, including academic outcomes, so a similar 

undertaking could identify particular challenges related 

to examining the CDE domains among this population. 

Some of this work has begun and one example is the NIHfunded Approaches and Decisions in Acute Pediatric TBI 

(ADAPT) study which utilizes a number of the pediatric 

CDEs in a pediatric population that has experienced a 

moderate to severe TBI.
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 35

Recommendations

Recommendations to address the gaps in TBI-related outcome measurement include the following:

➤ Develop comprehensive outcome measures that enable measurement of treatment 

effectiveness specific to the TBI population. It is essential to develop tools that are 

sensitive to changes associated with treatment and rehabilitation regardless of 

TBI severity.

➤ Increase validation of outcome measures in sub-populations. Conduct validation studies 

of outcome measures among particular sub-populations in which validity, reliability, and 

sensitivity have not been assessed previously. This is critical in order to expand scientific 

knowledge of outcomes and establish best practices for sub-populations, such as 

children, where evidence is still developing. 

➤ Better leverage health information technology (IT). Examine the expanding use of electronic 

health records as 1) a method for tracking patient progress from one level or system of 

care to another and 2) as a way to better examine the effectiveness of TBI interventions. 

➤ Create additional outcome measures that can be readily administered to non-native English 

speakers. The TRACK-TBI study found that a number of the measures recommended by the 

TBI CDE Workgroup could not be administered to non-native English speakers.

➤ Test and adapt the CDEs among children and adolescents. Similar to how the TRACK-TBI 

study examined the feasibility of implementing the CDEs in adults, a need exists 

to examine the feasibility of assessing the full range of CDEs among children and 

adolescents. 

➤ Assess promising CDE outcomes measures. Conduct additional studies of the measures 

the TBI CDE Workgroup identified as promising to determine whether they might warrant 

inclusion as recommended measures.

➤ Enhance involvement of patients and families in assessing rehabilitation outcomes. Increase 

inclusion of patient- and family-centered outcomes in research studies to better document 

the real-world utility of rehabilitation.
36 CENTERS FOR DISEASE CONTROL AND PREVENTIO
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 37

SECTION III

TBI Rehabilitation 

Goals and Purpose of TBI Rehabilitation

TBI rehabilitation is the medical and therapeutic services designed to improve and maintain cognitive, sensorimotor, and 

psychosocial functioning in persons with TBI. Ultimately, rehabilitation should “promote and optimize the activities, 

function, performance, productivity, participation, and/or quality of life of the person served” (CARF, 2013) and thus reduce 

the likelihood of TBI-related disability. 

Effectiveness of TBI Rehabilitation Practices

Types of TBI Rehabilitation Services

Persons with severe TBI are more likely to suffer cognitive and physical impairment compared with those with mild TBI 

(Dikmen et al., 1986, 1995; Gentilini et al., 1985; Gronwall and Wrightson, 1974). Multidisciplinary teams commonly 

provide coordinated care for those with severe TBI (Brasure, 2012; Sander and Constantinidou, 2008; Wertheimer et al., 

2008). The composition of a multidisciplinary team can include specialists trained in psychology, occupational therapy, 

physical therapy, speech-language pathology, therapeutic recreation, rehabilitation nursing, and case management. The 

inpatient rehabilitation team is typically under the direction of a physiatrist. This is a physician whose specialty is physical 

medicine and rehabilitation. The continuum of care is broad and ranges from inpatient rehabilitation to outpatient and 

community rehabilitation (Table 7).

Practices and interventions within each rehabilitation discipline address the specific health effects of TBI—each contributing 

to the overall effectiveness of rehabilitation. TBI rehabilitation consists of therapies broadly categorized as cognitive and 

physical. Cognitive rehabilitation (CR) consists of therapies used to manage deficits in thought processes and behavior, which 
38 CENTERS FOR DISEASE CONTROL AND PREVENTIO

includes comprehension, perception, and learning. Physical 

rehabilitation focuses on enhancing different forms of 

mobility by improving physical factors such as strength and 

endurance. 

Special Considerations for Rehabilitation 

Among Children with TBI

Children who are acutely disabled following a TBI are 

a vulnerable population. As a result, they might receive 

both inpatient and outpatient medical rehabilitation 

therapies—including occupational therapy, physical 

therapy, and speech-language therapy. However, long-term 

medical rehabilitation services often hinge on availability 

of financial resources to pay for care. The most frequently 

reported unmet health care need by parents is for cognitive 

services for their child. Thirty-one percent of parents 

report an unmet need at 12 months post-injury because of 

a lack of physician recommendation, lack of provision by 

school, or expense (Slomine, et al., 2006). 

Adding to the complications, frequently a gap occurs 

between the need for pediatric rehabilitation services and 

the receipt of needed services. This might be affected by 

the level of parents’ understanding regarding the need 

for therapy and educational services after their child is 

discharged from acute medical care (Gfroerer, Wade, 

and Wu, 2008; Slomine et al., 2006; Taylor et al., 2003). 

This disconnect can influence children’s receipt of both 

behavioral and academic or cognitive services. Typically, 

children who receive inpatient rehabilitation services are 

tracked after they transition out of inpatient rehabilitation. 

However, children who need services, but do not meet the 

requirements for inpatient services, might not be tracked. 

This can negatively affect whether they receive those 

needed services. 

Families of children who are affected by TBI face the 

challenge of negotiating two different service models 

following their injury: the medical model and the schoolbased model. Both models have different mandates 

for service access and varying delivery and funding 

considerations (Haarbauer-Krupa, 2009, 2012). In the 

medical model, rehabilitation services are provided based 

on assessment of medical necessity and injury recovery. 

In contrast, the school-based model provides services for 

TBI under the Individuals with Disabilities Education 

Act, which is based on medical documentation of the TBI 

and assessment results demonstrating learning needs. 

Table 7. TBI Rehabilitation programs and setting

Type of care Description/Eligibility/Funding

Skilled nursing 

facility/Sub-acute 

rehabilitation

In a separate setting than the 

hospital. Individuals require multiple

therapies that are delivered at less 

intensity. Length of stay average

30–60 days

Long-term care 

hospital (LTCH)

Individuals have a medically 

complicated status requiring ongoing 

pulmonary and cardiac support

Length of stay approximately 25 days

Home health Individuals are medically stable, seen 

in their homes, requiring more than 

one therapy service. May have slower

recovery and not able to participate in 

multiple therapies

Comprehensive 

inpatient 

rehabilitation

Can occur in acute hospital 

rehabilitation floor or specialized brain 

injury unit. Individuals are medically

stable and can benefit from 3 hours 

of therapy per day. A support system

for discharge is in place. Length of

stay 19-30 days

Day treatment/

Home/CommunityBased services

Can occur in a hospital or communitybased setting. Individuals are

medically stable and can participate 

in 5 hours of therapy per day

Outpatient 

rehabilitation

Delivered in a hospital facility or nonfacility private practice. Individuals are

medically stable and can participate 

in a single service

Post-acute 

residential

24/7 care for therapeutic behavioral 

monitoring based on individualized 

need for cognitive and behavioral 

support

Neurobehavioral 24/7 care for severe neurobehavioral 

symptoms. Able to participate in 5-6

hours of treatment per day. Length of

stay based on type of services utilized

Independent living Delivered in a variety of locations, 

including the home, group homes, or 

supported living programs

Vocational 

rehabilitation

State and private services for career 

counseling, training, and placement

Adapted from Zasler, Katz, and Zafonte, 2013
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 39

This has resulted in under-identifying affected students 

for educational support services (DiScala and Savage, 

2003; DiScala, Osberg, and Savage 1997; Glang, Todis, 

Thomas, Hood, Bedell, and Cockrell, 2008; Hawley, 

2004). Although return to classroom protocols have been 

developed based on expert consensus, adoption of these 

protocols has been limited due to a need for more education 

for school personnel regarding how to best implement a 

return to the classroom (Dettmer, Ettel, Glang, & McAvoy, 

2014; Halstead, et al., 2013). 

Although most medical rehabilitation therapies are 

discontinued within the first year post-injury, the effects 

of pediatric TBI on cognition, behavior, and adjustment 

frequently persist and can worsen over time. However, a 

service delivery gap often exists because few children receive 

special educational services in schools (Glang, Tyler, Peason, 

Todis, and Morvant, 2004). Only 50.9% of pediatric 

TBI patients receive hospital-to-school transition services 

(Glang et al., 2008). Equally troubling, the need for special 

education services is not identified among 33% of children 

(Glang et al., 2008). Obtaining the appropriate frequency 

and intensity of services in the school can be affected by a 

lack of understanding by staff regarding the need to integrate 

medical and school services (Haarbauer-Krupa, 2009). 

Reports of unmet health care needs and underidentification of children affected by TBI in schools are 

partly related to the difficulties parents face in navigating 

the continuum of services following TBI. In addition, 

students who sustain less severe injuries, concussions or 

mild TBIs, often fail to receive school accommodations 

despite recommendations that accommodations be made 

available for several weeks to months post-injury (Gioia, 

Kenworthy, and Isquith, 2010). As a consequence, both 

parents and school personnel can become frustrated 

and discouraged by a child’s continuing difficulties and 

disruption to their normative development (Chapman 

et al., 2010). 

Overview of Knowledge and Practice 

in Rehabilitation

The following sections review the current state of 

knowledge and practice regarding the effectiveness of 

cognitive and physical rehabilitation for TBI. This section 

is followed by a description of longer-term approaches 

that might be employed, including community-based 

rehabilitation and vocational rehabilitation.

Cognitive Rehabilitation

Definition, Methods, and Goals 

Cognitive rehabilitation (CR) focuses on improving 

cognitive deficits and the effects of cognitive impairment 

on interpersonal communication, behavior, emotions, 

community participation, and academic and vocational 

functioning. Services are directed to achieve functional 

changes by (1) reinforcing, strengthening, or reestablishing 

previously learned patterns of behavior, or (2) establishing 

new patterns of cognitive activity or compensatory 

mechanisms for impaired neurological systems (Harley 

et al., 1992). 

CR is a collection of treatments tailored to cognitive 

impairments and psychological health. It is also a core 

component of TBI rehabilitative care for those persons 

with moderate and severe TBI (Cicerone et al., 2005). 

It is provided in approximately 95% of all TBI rehabilitation 

programs in the United States (Mazmanian, Kreutzer, 

Devany, and Martin, 1993). The scope, duration, timing, 

and intensity of CR services for post-acute rehabilitation 

are often affected by the availability of financial resources, 

including the level of insurance coverage available to 

an individual patient (Katz, Ashley, O’Shanick, and 

Connors, 2006). 

CR for TBI is rooted in one of two basic models: restorative 

interventions and compensatory skill development. Restorative 

interventions are designed to improve cognitive functioning 

through practice. The cognitive skills practiced are 

targeted in a hierarchical fashion, from less sophisticated 

to more complex components of cognitive functioning. 

Compensatory skills development involves the teaching 

of skills for adaptation to impaired cognitive functioning. 

Within the medical model, CR is administered through the 

disciplines of neuropsychology, speech-language pathology, 

and occupational therapy. However, CR for children is 

rarely delivered in medical settings. Instead, it is delivered 

through schools with a focus on acquisition of academic 

content (Haarbauer-Krupa, 2009). 

Various technological approaches can be employed as part 

of CR. For example, specialized training with external 

assistive devices (e.g., personal data assistants [PDAs], 

global positioning system [GPS] devices, paging systems, 

and smartphones) can be implemented to make it easier 

to perform activities of daily living. For example, pager 

reminders can prompt patients to take medication, get up 
40 CENTERS FOR DISEASE CONTROL AND PREVENTIO

in the morning, and perform daily housekeeping tasks 

(Wilson, Scott, Evans, and Emslie, 2003). Therapist 

guidance is required for selecting a device that best suits 

cognitive capacities, as well as support for programming 

and maintenance of the device (LoPresti, Mihailidis, and 

Kirsch, 2004). 

Effectiveness of Cognitive Rehabilitation

Several scientific reviews have synthesized the existing 

literature on CR interventions to determine their 

effectiveness in improving cognitive functioning (Cicerone 

et al., 2000, 2005, 2011; Institute of Medicine [IOM], 

2011; Rohling, Faust, Beverly and Demakis, 2009). For 

example, the Cognitive Rehabilitation Task Force of the 

ACRM Brain Injury Interdisciplinary Special Interest 

Group evaluated 370 studies and found that CR is effective 

during the post-acute period, even 1 year or more after 

injury (Cicerone et al, 2000, 2005, 2011). Further analysis 

combining results from a subset of these studies (Rohling 

et al., 2009) concluded that the scientific evidence supports 

the effectiveness of CR in patients with moderate and 

severe TBI. 

However, an Institute of Medicine (IOM) committee 

concluded that the evidence was insufficient to provide 

practice guidelines, particularly with respect to selecting 

the most effective treatments for a specific person 

(IOM, 2011). The insufficiency of the evidence was 

largely attributed to limitations in research designs for 

rehabilitation evaluation studies. Flaws identified included 

the lack of operational definitions for different forms of 

CR therapy, small sample sizes, the wide range of outcomes 

targeted, and lack of testing for treatment moderators. 

Taken together, the limitations identified suggest the need 

for more research to determine the effectiveness of specific 

CR therapies and the circumstances in which they confer 

the most benefit. 

And yet, some studies do support the effectiveness of 

specific CR interventions. Direct attention training and 

instruction in the use of a memory notebook or problemsolving strategies have been found to be effective in 

promoting the development of compensatory strategies 

(Cicerone et al., 2011). Also, metacognitive (i.e., selfawareness) training has been shown to improve attention 

and alleviate executive function deficits contributing to 

poor self-monitoring and self-regulation of behaviors 

(Cicerone et al., 2011). Evidence also is sufficient to 

support the effectiveness of interventions and cognitivelinguistic therapies designed to improve functional 

communication deficits after TBI (Cicerone et al., 2011; 

Demir, Altinok, Aydin, and Koseoglu, 2006). 

In summary, the literature suggests that CR is effective in 

teaching those affected by TBI to learn and apply skills 

to compensate for cognitive limitations, although there is 

currently an insufficient body of evidence that demonstrates 

the effectiveness of this method in treating the underlying 

cognitive deficits caused by a TBI (IOM, 2011). However, 

insufficient evidence does not mean that CR treatment is 

not effective, but rather that not enough research of high 

quality has demonstrated positive outcomes. Specifically, 

research is needed to identify the patient and treatment 

factors that contribute to successful outcomes while 

addressing methodological concerns (Cicerone et al., 2011; 

Rohling, et al., 2009). Finally, additional studies are needed 

to evaluate therapies used to restore attention and memory 

(IOM, 2011).

Physical Rehabilitation 

Definitions, Methods, and Goals 

Physical rehabilitation addresses the effects of TBI on 

sensory and motor systems. Therapy sessions include the 

use of physical modalities (e.g., massage, exercise, or applied 

heat or cold), therapeutic exercise, adaptive equipment, 

orthotics, and medications. As persons with TBI progress 

through recovery, a greater emphasis is placed on activity 

level, conditioning, and participation in community 

activities. Physiatrists, physical therapists, and occupational 

therapists are most often involved in physical rehabilitation. 

Other disciplines also can be involved in motor skill 

acquisition. Therefore, having an interdisciplinary 

treatment team in place is essential (Sullivan, 2007).

For persons at a more advanced stage of recovery, the 

primary goal of physical rehabilitation is to improve muscle 

strength, balance, motor control, and functional ability. 

Adjusting the rehabilitation session to the individual 

person is essential during this stage (Crisis Prevention 

Institute, 2005). For persons who receive treatment in 

inpatient or outpatient rehabilitation programs, treatment 

progresses and incorporates strategies to promote 

independence in self-care activities. These strategies 

include addressing functional mobility, such as walking and 

climbing stairs. Additionally, various interventions can be 
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 41

used to address specific impairments (Acker and Linder, 

2004; McCulloch, Blakley, and Freeman, 2005) such 

as disturbances of balance and equilibrium (ShumwayCook, 2007). 

Effectiveness of Physical Rehabilitation 

Evidence supports the general effectiveness of physical 

rehabilitation in improving TBI outcomes (Bland, 

Zampieri-Gallagher, and Damiano, 2011; Betker, Desai, 

Nett, Kapadia, and Szturm, 2007; Irdesel, Aydiner, and 

Akgoz, 2007; Mossberg, Amonette, and Masel, 2010; 

Scherer and Schubert, 2009; Shaw et al., 2005). Persons 

who have little or no response to stimulation (i.e., comatose, 

vegetative or minimally conscious state) benefit from 

activities that prevent involuntary muscle contraction or 

muscle shortening and skin breakdown. Regularly scheduled 

passive range-of-motion exercises and body positioning are 

techniques that are used to positive effect (Winkler, 2013). 

To assist with physical rehabilitation, casts or devices are 

helpful in treating muscle shortening at the knee, ankle, 

wrist, and elbow (Singer, Jegasothy, Singer, and Allison, 

2003). Progression from lying down to being able to sit 

up allows the physical therapist to monitor and promote 

responsiveness, head and trunk control, and improved 

pulmonary function. Assistance in unsupported sitting and 

a proper wheelchair seating assessment also are beneficial 

for contraction and skin-breakdown prevention. Equipment, 

such as standing frames or tilt tables, can be used to 

maintain bone structure, elongate shortened muscles, 

challenge endurance, and stimulate the minimally conscious 

person. Body-weight-supported (BWS) gait devices 

and knee-ankle-foot orthotics can be used with manual 

assistance to initiate standing postures. BWS devices can 

lead to improved cardiovascular function and assist with 

the beginning of walk training (Mossberg, Orlander, and 

Norcross, 2008; Wilson and Swaboda, 2002). 

Evidence supports the treatment efficacy for several specific 

physical rehabilitation methods. Gaming and virtual 

reality-based treatment methods are emerging as an adjunct 

to physical therapy standards of practice for treatment 

of persons with TBI (Betker et al., 2007; Scherer and 

Schubert, 2009). One study demonstrated the effectiveness 

of improved goal-oriented, task-specific training with the 

use of a gaming system to promote practice of short sitting 

balance control for persons with a TBI. Additionally, a 

game-based training tool yielded an increase in practice 

volume and attention span, and furthermore, improvements 

in dynamic sitting balance control (Betker et al., 2007). 

Certain evidence indicates that virtual reality and other 

methods to improve vestibular function and balance result 

in improvements in both gait and gaze stability of persons 

with TBI sustained during blasts (Scherer and Schubert, 

2009). However, approaches such as motor interventions, 

proprioceptive muscle training, and neurodevelopmental 

treatment have been used in clinical practice with limited 

research regarding their effectiveness. 
42 CENTERS FOR DISEASE CONTROL AND PREVENTIO

Pharmacologic intervention for reduction of involuntary 

muscle contraction, a common physical effect of severe 

TBI, is a growing field. Chemo-neurologic agents can be 

administered locally in order to target specific muscles. 

Orally ingested medications can also offer relief from 

involuntary muscle contraction. However, those persons 

who most often need intervention for muscle contraction 

are sometimes the most sensitive to the cognitive side effects 

of pharmacologic interventions, particularly in the area of 

attention (Esquenazi et al., 2012).

Rehabilitation Services Following Acute 

Rehabilitation

Community-based Programs

Although numerous persons with TBI are able to return 

to their communities when discharged from the hospital 

or inpatient rehabilitation, a portion will continue to 

require therapy services and support for independent 

living, family life, work, and leisure activities. To meet this 

need, community-based programs help persons affected 

by TBI reclaim a presence in the community that is 

“meaningful, satisfying and socially productive” (Volpe, 

2012). Community-based rehabilitation programs also are 

known as Community Integrated Rehabilitation (CIR; 

Trudel, Nidiffer and Bartg, 2007), Community Integration 

Programs (Glenn, Goldstein, Selleck and Rotman, 2004) 

or Post-Acute Brain Injury Rehabilitation Programs 

(Malec and Basford, 1996). Unlike medical rehabilitation 

programs, CIR programs often form partnerships with state 

agencies, brain injury support groups, and volunteers. Such 

programs can be described as either supportive—providing 

assistance to persons with TBI to maintain their current 

status—or more intensive, with goals related to improving 

health and functional abilities, and returning to work 

and/or community participation (Malec, 2012). Homebased rehabilitation, telephonic or web-based counseling 

focused on helping a person with TBI identify needed and 

available outpatient services, is one type of communitybased program that might be funded by medical insurance 

(Phillips, et al., 2012). Types of community-based program 

models are described in Table 8. Eligibility for communitybased programs is determined by 1) program requirements 

for funding and services offered and 2) individual level of 

functioning and funding resources. 

Some states provide support for community-based 

rehabilitation programs. Consequently, funding levels and 

the availability of programs vary by state. Because of the 

heterogeneity of these programs, effectively describing their 

admission eligibility criteria, composition of services, and 

other key characteristics is difficult. As a result, research on 

community-based program outcomes is limited. Despite 

limitations with respect to research support, communitybased program development continues in state and local 

communities because of the recognition of the chronicity of 

needs for persons affected by TBI.

Table 8. Types of community-based programs in the United State

Type of program Description Participant characteristics

Neurobehavioral Residential setting, intensive behavioral management Severe behavior disturbances that require 24-hour 

supervision

Residential community Residential setting with full community integration, 

comprehensive clinical team treatment

A holistic milieu-oriented environment for individuals 

who require 24-hour supervision

Comprehensive holistic Day treatment programs, integrated multimodal 

rehabilitation; outpatient programs

Need for immediate services; benefit from improved 

awareness

Home-based 

Education and advisement; telephonic and web-based 

support; counseling related to availability of outpatient 

services

Ability to reside at home and direct self-care

Club house 

Participants as members of a community who 

have decision-making rights; key features promote 

community participation

Ability to take responsibility for building own capacity

Source: Malec et al., 2012; Trudel et al.; 2007; Volpe, 2012
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 43

Vocational Rehabilitation Services 

For persons affected by TBI, vocational rehabilitation 

(VR) is a treatment option that offers assistance with 

career planning and achievement of career goals. VR 

rehabilitation can include assessment, counseling, 

guidance, training and education, and on-the-job training. 

Because of the range in severity and types of difficulties 

among persons affected by TBI, person-centered and 

individualized planning is needed to comprehensively 

address the goal of returning to work. The models of VR 

and a brief description of each are provided in Table 9. 

Models of VR program implementation vary by state, but 

primarily address three areas of concern: work preparation, 

work trials, and supported employment (Tyerman, 2012). 

Evidence indicates that VR clients who are successfully 

employed can substantially increase their income and 

decrease their reliance on public support ( Johnstone et al., 

2006; Zuger, Brown, O’Neill, Stack, and Amitai, 2002). 

No comprehensive systematic research on access, use, and 

effectiveness of state-based VR programs is available; 

thus, understanding their organization and effectiveness 

is limited. However, certain research has established that 

receipt of VR services is a better predictor of vocational 

success for persons with moderate-to-severe injuries than 

injury, psychological, or demographic factors ( Johnstone, 

Vessell, Bounds, Hoskins, and Sherman, 2003). In 

addition, on-the-job training, vocational counseling, 

supported employment, and case-management services 

have been identified as predictors of positive employment 

outcomes (Chesnut et al., 1998; Johnstone et al., 2006). 

Table 9. Models of vocational rehabilitation (VR) following traumatic brain injury in the United State

Program-based vocational 

rehabilitation

A program-based approach offers intensive individualized cognitive and work skills, guided work trials, and 

assistance with placement

Individual placement 

model of supported 

employment

This model involves job placement, on the job training, job coaching, and long-term support

Case coordination 

approach

In this approach, VR is a part of an overall model of care that includes other rehabilitation services. Focus is o

early intervention and continuity of care across time

Consumer-directed 

approach

Described as the “Clubhouse Model,” individuals with brain injury play a major role in running the program

Professional staff are involved “opportunistically” according to members’ goals, preferences, and activities

Those with requisite skills receive support for community-based employment

Source: Fadyl and McPherson, 2009; Tyerman, 2012
44 CENTERS FOR DISEASE CONTROL AND PREVENTIO

Gaps in Evaluating the Effectiveness of TBI Rehabilitation

Evaluating the effectiveness of TBI rehabilitation 

is a challenge because of the complexity of TBI 

pathophysiology, limitations of common research 

methodology, and the diversity of rehabilitation therapies 

and settings (Brasure, 2012). TBI can have numerous 

health effects that manifest differently in each person. 

As a result, therapies must be tailored to the individual 

person. This also has a bearing on research because finding 

a sizeable study population with similar attributes for 

outcome studies is challenging. In addition, pre-injury 

factors such as age, pre-injury functioning, socioeconomic 

status, caregiver and family functioning, social support, 

and access to care, can influence the recovery of a patient. 

Also, qualities such as the timing, duration, and intensity of 

treatment can have a bearing upon treatment effectiveness. 

Further, these critical characteristics of treatment can be 

heavily influenced in the real world by the level of insurance 

coverage available to a person. 

Methodological concerns remain in the area of conducting 

and interpreting research on the effectiveness of TBI 

rehabilitation. Although considered the gold standard, 

randomized control trials (RCTs) are challenging and 

costly to implement. Also, RCTs are frequently conducted 

in an ideal environment and might not generalize to the 

inherent complexity of TBI treatment in the real world. 

Related, the content of therapy sessions in research and 

practice might not always be well-defined, which results 

in variability among different facilities and practitioners. 

Some have called for increased efforts to manualize 

treatment (i.e., develop and adhere to specific treatment 

instructions) to enhance the comparability of treatment 

across treatment sites and research studies (Gordon, 

2010). However, it may be premature to focus too many 

resources on RCTs, as some have suggested the need for a 

better description (and testing) of the theoretical basis for 

rehabilitation, and the identification of the foundational 

components of effective rehabilitation (Gordon, 2010). 

Among the foundational questions that remain, the current 

body of evidence does not permit the identification of 

the optimal dose or intensity of therapy, the ideal timing 

of therapy in the recovery process, or the necessary 

modifications for subpopulations. The available evidence is 
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 45

frequently limited to crude measures of dose (e.g., length 

of stay or number of hours spent in physical, occupational, 

or speech therapies). Also, with regard to the intensity 

of rehabilitation, a growing body of research on TBI and 

recovery has demonstrated benefits of high-intensity 

intervention, even during later stages of recovery (Turkstra, 

Holland, and Bays, 2003). 

Scientific reviews indicate that a higher dose of therapy 

is associated with better functional outcomes (Kennedy 

et al., 2008; Sohlberg et al., 2003). Related to the 

timing of rehabilitation, evidence suggests that intensive 

intervention in the very acute stage of motor recovery 

(less than 2 months post-injury) is not advantageous 

and can actually exacerbate deficits (Dromerick et al., 

2009; Kleim and Jones, 2008). Addressing the need to 

better understand questions related to dose, intensity, and 

timing of rehabilitation will require coordinated effort by 

several facets of the rehabilitation research community to 

develop usable and meaningful models for classifying and 

measuring rehabilitation interventions. 

Robust research methods are needed to resolve these gaps 

within each discipline or specialty of rehabilitation (i.e., 

cognitive, physical, community-based, and vocational). 

More definitive answers to these questions could have a 

substantial effect on the policies of third-party payers and 

better ensure that sufficient levels of treatment are covered. 

Increased evaluation of alternative delivery models of 

rehabilitation and long-term medical care for TBI is 

needed. For example, the use of tele-health and web-based 

technologies that provide access to expert consultation via 

the telephone and internet can help to overcome barriers 

to rehabilitation access, such as geographic residence 

and lack of transportation. Also, the need to develop 

and evaluate service models must be addressed so that 

parents will have the assistance to better navigate the 

post-acute rehabilitation setting, ensuring that needed 

services for children with TBI are received. Furthermore, 

TBI can affect a person throughout their lifespan and 

additional medical conditions might develop such as 

neurodegenerative diseases. Therefore, it is important 

to establish integrated healthcare models that support 

ongoing treatment, community integration, and cognitivebehavioral support of persons with TBI.

Comparative effectiveness studies are needed to examine 

the cost-benefit ratio of rehabilitation for TBI, and to 

determine how the cost-benefit ratio is related to the 
46 CENTERS FOR DISEASE CONTROL AND PREVENTIO

length, duration, and intensity of treatments. Beyond 

the impact of rehabilitation on health outcomes, the 

effectiveness of TBI rehabilitation also can be supported by 

documenting the overall economic benefit of rehabilitation. 

These types of analyses are critical as they can be powerful 

drivers of decisions made by funders, government agencies, 

and managed care organizations. Attempts should be made 

within all rehabilitation outcomes studies to measure the 

economic impact of particular interventions.

Inclusion of patient- and family-centered outcomes in 

research studies should be continued and expanded to 

better document the real-world utility of rehabilitation. 

Persons with TBI and persons who provide support, such 

as family and friends, can offer critical insights about the 

real-world effects of rehabilitation.

Research is lacking relative to the effectiveness of 

rehabilitation services following acute rehabilitation, 

such as community-based rehabilitation and vocational 

rehabilitation interventions. Program models for these 

types of rehabilitation vary by state, creating challenges 

in characterizing and evaluating the effectiveness of these 

types of programs. Research examining promising models 

of post-acute rehabilitation might be a good place to begin 

in demonstrating effectiveness. Despite the ongoing needs 

of persons with TBI for services after acute rehabilitation, 

less insurance coverage is typically available for these types 

of services. Demonstrating the effectiveness of post-acute 

rehabilitation services would likely be helpful in expanding 

coverage for these services. 

In sum, the field of TBI rehabilitation has progressed 

considerably within the past 20 years. Evidence suggests 

that rehabilitation services can improve a person’s quality of 

life and can improve the likelihood of achieving community 

integration, including returning to work or school, living 

independently, and enjoying social and leisure activities. 

More work is needed to understand the specific factors 

related to the achievement of improved outcomes for TBI. 

Researchers and practitioners must collaborate to identify 

and pursue opportunities to strengthen the rehabilitation 

system and coordination of care, so that appropriate 

resources are available.
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 47

Recommendations

Recommendations to address the gaps in understanding the current state of rehabilitation for TBI and the effectiveness of 

various rehabilitation approaches include the following:

➤ Improve understanding of optimal rehabilitation protocols. Conduct research studies to 

better examine the optimal timing, intensity, and dose of rehabilitation interventions.

➤ Study rehabilitation effectiveness among subpopulations. Conduct research studies 

to determine the effectiveness of TBI rehabilitation services among groups in which 

effectiveness has not been specifically examined, such as children. Examining 

effectiveness among particular sub-populations can help to identify ways in which 

rehabilitation might be tailored to the particular needs of sub-groups to optimize 

effectiveness.

➤ Create service models for parents and caregivers to optimize rehabilitation services. 

Develop and evaluate service models that will assist parents to better navigate the 

post-acute rehabilitation setting, ensuring that needed services for children with TBI 

are received. 

➤ Strengthen understanding of the TBI continuum of care after acute inpatient rehabilitation. 

Conduct research studies to examine the effectiveness of rehabilitation services following 

acute inpatient rehabilitation, such as community-based rehabilitation and vocational 

rehabilitation. 

➤ Further assess the cost benefit of TBI rehabilitation to enhance understanding of cost 

effectiveness. Conduct studies examining the cost-benefit ratio of TBI rehabilitation 

interventions and examine how the cost-benefit ratio is related to the dose, duration, 

and intensity of rehabilitation. Beyond demonstrating the health-related effects 

of rehabilitation, the effectiveness of TBI rehabilitation can also be supported by 

documenting the resulting economic benefit. 

➤ Further assess the need to increase use of alternative sources for delivering rehabilitation 

services, such as telemedicine (including web-based consultation), mobile services, and the 

use of lay health advisors. Evaluate the effectiveness and cost effectiveness of alternative 

delivery models—especially those that might overcome barriers to rehabilitation access 

caused by factors such as rural residence and lack of transportation.

➤ Expand use of promising technologies for use in rehabilitation interventions. Increase 

widespread dissemination of emerging practices such as the use of global positioning 

system devices, paging systems, and smartphones to aid with cognitive rehabilitation. 

➤ Implement integrated systems to support the ongoing follow-up of persons affected by TBI. 

Develop healthcare models that integrate medical and community services that support 

the lifelong needs of persons affected by TBI.
48 CENTERS FOR DISEASE CONTROL AND PREVENTIO
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 49

Conclusion

Understanding the epidemiology of TBI, its associated consequences, and the availability and effectiveness of rehabilitation 

interventions are crucial to improving the quality of life of those with a TBI. Prevention is the key public health strategy 

to reduce the burden of TBI. However, because preventing all TBIs is impossible, an imperative for those in public 

health practice, clinical practice, and research is to design and evaluate effective strategies to mitigate the health effects of 

TBI. Maintaining a comprehensive and coordinated system of rehabilitation interventions is critical to achieve this end. 

Considerable progress has been made in identifying effective rehabilitation interventions after a TBI, but much work 

remains to be done. This report outlines many of those opportunities from understanding the TBI burden better to 

improving TBI rehabilitation.

CDC was asked by Congress to address the need for evidence-based guidelines for TBI rehabilitation. The development 

of guidelines is a systematic process in which a panel of experts assesses the scientific literature to produce practice 

recommendations. Ideally, any guidelines developed will help clinicians to make evidence-based decisions supported 

by research. 

Although previous research has demonstrated the effectiveness of a number of TBI rehabilitation services, much more 

research is needed before evidence-based guidelines can be identified. The complex nature of TBI injuries and TBI 

rehabilitation makes it challenging to identify the type of specific conclusions that can be translated into recommendations 

for clinical use. The heterogeneous nature of TBI-related injuries and a large set of rehabilitation services are just some of 

the particular challenges that make TBI rehabilitation research difficult. These challenges must be addressed in order to 

improve the evidence base before proceeding to guideline development.
50 CENTERS FOR DISEASE CONTROL AND PREVENTIO

Some of the specific challenges include the following: 

➤ Dose, Intensity, and Timing of 

Rehabilitation: The current body 

of evidence does not permit 

the identification of the optimal 

dose or intensity of therapy, the 

ideal timing of therapy in the 

recovery process, or the necessary 

modifications for subpopulations. 

➤ Relevance of New Technologies:

To help overcome barriers to 

rehabilitation access such as 

geographic residence and lack 

of transportation, alternative 

delivery models of rehabilitation 

(e.g. tele-health and tele-medicine 

technologies) must be evaluated. 

➤ Continuity of Care and Service 

Delivery: There is a need to 

develop and evaluate alternative 

service models that can assist 

parents and other caregivers in 

better navigating the post-acute 

rehabilitation setting.

➤ Comparative Effectiveness and 

Cost of Rehabilitation: Comparative 

effectiveness studies examining 

the effectiveness and benefits 

of TBI rehabilitation are lacking. 

In addition, studies examining 

the relationship between the 

cost-benefit ratio and the 

length, duration, and intensity of 

rehabilitation services are needed. 

➤ Post-Acute Rehabilitation Care:

Research that focuses on the 

effectiveness of rehabilitation 

services following acute 

rehabilitation, such as communitybased rehabilitation and vocational 

rehabilitation interventions is 

lacking. 

Although key gaps are evident in TBI rehabilitation 

research that present challenges in identifying practice 

guidelines, signs of substantial progress are also evident. 

Chief among these are the efforts of the TBI Common 

Data Elements (CDE) Project. The recommendations 

made by the TBI CDE Workgroup will bring much 

needed consistency to TBI research and will be helpful in 

improving study design and comparability between studies. 

In addition, the TRACK-TBI study established the 

feasibility of implementing a broad range of TBI CDEs in 

a single study. Efforts such as these are critical examples of 

the type of coordinated effort that is required to move the 

evidence base forward to better help persons with TBI to 

lead more healthy and productive lives.
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 51
52 CENTERS FOR DISEASE CONTROL AND PREVENTIO
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 53

APPENDIX A

CDC Traumatic Brain Injury Rehabilitation 

Authors and Contributors

Senior Editors 

Jeneita M. Bell, MD, MPH

Medical Officer 

Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

E. Lynn Jenkins, PhD 

Senior Advisor for Program Integration

Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Matt Breiding, PhD

Traumatic Brain Injury Team Lead

Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Juliet Haarbauer-Krupa, PhD, CCC-SLP

Health Scientist

Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Associate Editor

Michael R. Lionbarger, MPH

Health Scientist

Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention
54 CENTERS FOR DISEASE CONTROL AND PREVENTIO

CDC Contributing Staff

Grant Baldwin, PhD, MPH

Director

Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

David Sleet, PhD, FAAHB

Associate Director for Science

Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Lisa C. McGuire, PhD

Traumatic Brain Injury Team Lead

Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Arlene Greenspan, DrPH, MPH, PT

Associate Director for Science

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Rita Noonan, PhD

Chief

Health Systems and Trauma Systems Branch

Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Victor G. Coronado, MD, MPH

Medical Officer

Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Christopher A. Taylor, PhD

Epidemiologist

Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Lisa Garbarino

Public Health Analyst

Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Tabitha Herzog

Medical Student

University of California, Los Angeles

CDC Experience Fellow

Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 55

Expert Panel Members

Beth Ansel, PhD, CCC-SLP

Director

TBI and Stroke Rehabilitation 

Research Program

National Center for Medical 

Rehabilitation Research 

Eunice Kennedy Shriver National Institute of 

Child Health and Human Development 

Ruth Brannon, MSPH, MA

Director of Research Sciences

National Institute on Disability and Rehabilitation 

Research (NIDRR)

U.S. Department of Educati

Roberta DePompei, PhD

Professor of Speech-Language Pathology

School of Speech-Language Pathology 

and Audiology

The University of Akron

Marcel Dijkers, PhD

Mount Sinai School of Medicine

Department of Rehabilitation Medicine

Jeanne E. Dise-Lewis, PhD 

Professor

Department of Rehabilitation Medicine 

and Psychiatry

University of Colorado Anschutz 

Medical Campus

Timothy R. Elliott, PhD

Editor in Chief

Journal of Clinical Psychology

Professor

Department of Educational Psychology

Texas A&M University

Linda Ewing-Cobbs, PhD

Professor of Pediatrics and Psychiatry and 

Behavioral Sciences

Director

Dan L. Duncan Children’s

Neurodevelopmental Clinic

University of Texas Health Science Center 

at Houston

Kelli Williams Gary, PhD, MPH, 

OTR/L

Assistant Professor

Department of Occupational Therapy

Virginia Commonwealth Universit

Wayne Gordon, PhD

Professor

Rehabilitation Medicine

Department of Rehabilitation Medicine

Mount Sinai Medical Center

Tessa Hart, PhD

Scientist

Moss Rehabilitation Research Institute

Research Professor

Department of Rehabilitation Medicine

Jefferson Medical College

Stuart W. Hoffman, PhD

Scientific Program Manager for Brain 

Injury Rehabilitation Research and 

Development Service

U.S. Department of Veterans Affa

Gillian Hotz, PhD

Director

KiDZ Neuroscience Center

Director

Concussion, WalkSafe and BikeSafe Programs

Associate Research Professor

Department of Neurosurgery

University of Miami Miller School 

of Medicine

Susan Johnson, MA, CCC-SLP, 

CCM

Director of Brain Injury Services

Shepherd Center 

Brick Johnstone, PhD, ABPP

Professor

Department of Health Psychology

University of Missouri

James P. Kelly, MA, MD, FAAN

Director

National Intrepid Center of Excellence

Walter Reed National Military 

Medical Center

Jeffrey S. Kreutzer, PhD, ABPP, 

FACRM 

Director

Neuropsychology and Rehabilitation 

Virginia Commonwealth University School

of Medicine

A. Cate Miller, PhD

Program Manager

TBI Model Systems Centers

National Institute on Disability and 

Rehabilitation Research 

U.S. Department of Educati

Mary Vining Radomski, PhD, 

OTR/L

Clinical Scientist and Occupational Therapist

Sister Kenny Research Center

ORISE Fellow, Army Office of the Surgeon General

Ronald T. Seel, PhD 

Director

Brain Injury Research

Crawford Research Institute

Shepherd Center

Marilyn Spivack

Neuro Trauma Outreach Specialist

Spalding Rehabilitation Hospital

Stacy Suskauer, MD

Director of the Brain Injury Program

Kennedy Krieger Institute

Assistant Professor of Physical Medicine and 

Rehabilitation and Pediatrics

Johns Hopkins University School 

of Medicine

Gerry Taylor, PhD, ABPP/CN

Professor of Pediatrics

Case Western Reserve University

Rainbow Babies and Children’s Hospital

University Hospitals Case Medical Center

Child Developmental Center

Bonnie Todis, PhD

Center on Brain Injury Research and Training

University of Oregon 

CAPT Jack Tsao, MD 

Neurologist and Director of TBI Programs 

US Navy Bureau of Medicine and Surgery

Shari L. Wade, PhD

Director of Research and Research Professor of 

Pediatrics

Cincinnati Children’s Hospital Medical Center

Gale Whiteneck, PhD, FACRM

Director of Research

Craig Hospital, Englewood, CO

Timothy J. Wolf, OTD, MSCI, 

OTR/L

Assistant Professor, Program in Occupational 

Therapy

Department of Neurology

Washington University School of Medicine
56 CENTERS FOR DISEASE CONTROL AND PREVENTIO

Subject Matter Experts and Contributors

Amanda Acord-Vira, 

MOT/L, CBIS

Assistant Professor

West Virginia University School of Medicin

Department of Human Performance and 

Applied Exercise Science

Division of Occupational Therapy

William B. Barr PhD, ABPP

Chief of Neuropsychology

New York University School of Medicine

NYU Comprehensive Epilepsy Center

Heather Belanger, PhD, ABPP

Clinical Neuropsychologist

Tampa VA Hospita

Assistant Professor, Psychology Department

University of South Florida

Debra Braunling-McMorrow, PhD

Licensed Clinical Psychologist 

Medical-Legal Consultant 

International Consultant

Lisa Brenner, PhD, ABPP 

Director

Veteran Integrated Service Network 1

Mental Illness Research, Education, and 

Clinical Center 

David Burke, MD

Professor and Chairman

Department of Rehabilitation Medicine

Emory University School of Medicine

Keith D. Cicerone, PhD, ABPP-Cn

Director of Neuropsychology

Neuropsychology and Cognitive 

Rehabilitation

JFK-Johnson Rehabilitation Institute

John D. Corrigan, PhD, ABPP

Professor

Department of Physical Medicine

and Rehabilitation

The Ohio State University’s Wexner Medical 

Center

Andrew Cullen Dennison, MD

Staff Physical Medicine and 

Rehabilitation Physician

Shepherd Center

Matthew Dodson, OTD, OTR/L

Supervisor

TBI Occupational Therapy

Walter Reed National Military Medical 

Center at Bethesda

Andrew Gellar, MD

Epidemic Intelligence Service Officer

Centers for Disease Control and Prevention

Joseph T. Giacino, PhD 

Director of Rehabilitation Neuropsychology 

Spaulding Rehabilitation Hospital 

Associate Professor 

Department of Physical Medicine and 

Rehabilitation 

Harvard Medical School

Clare Giuffrida PhD, 

OTR/L, FAOTA

Chair and Associate Professor 

Rush University Medical Center

Ann Glang, PhD

Senior Fellow/Research Professor

Teaching Research Institute

Principal investigator

Oregon Center for Applied Science

Cindy Harrison-Felix, PhD

Assistant Director of Research

Craig Hospital

Assistant Clinical Professor

Department of Physical Medicine 

and Rehabilitation

University of Colorado Denver

Dorothy A. Kaplan, PhD

Senior Specilaist, Neuropsychology

Altarum Institute

Subject Matter Expert

Defense Veterans Brain Injury Center

(DVBIC

James F. Malec, PhD, 

ABPP-Cn, Rp

Professor and Research Director

PM&R, Indiana University School of 

Medicine and Rehabilitation Hospital of 

Indiana

Georgina Peacock, MD

Medical Officer

Division of Human Development 

and Disability

National Center on Birth Defects and 

Developmental Disabilities 

Centers for Disease Control and Prevention

Janet M. Powell, PhD, 

OTR/L, FAOTA

Associate Professor and Head

Division of Occupational Therapy

Department of Rehabilitation Medicine

University of Washington

Tracy Rice, PT, MPH, NCS

Assistant Professor

West Virginia University School of Medicin

Department of Human Performance and 

Applied Exercise Science

Division of Physical Therapy

Mark Swanson, MD, MPH

Senior Medical Advisor 

Division of Human Development 

and Disability

National Center on Birth Defects and 

Developmental Disabilities 

Centers for Disease Control and Prevention

Lyn Turkstra, PhD

Professor

Department of Communicative Disorders, 

Department of Neurological Surgery and 

Neuroscience Training Program

University of Wisconsin-Madison

Ford Vox, MD

Staff Physical Medicine and 

Rehabilitation Physician

Shepherd Center
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 57
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66 CENTERS FOR DISEASE CONTROL AND PREVENTIO

Acknowledgement

We would like to thank Daniel M. Sosin, MD, MPH, FACP, 

who also made contributions to this report as Acting Director of 

the National Center for Injury Prevention and Control.
TRAUMATIC BRAIN INJURY IN THE UNITED STATES: EPIDEMIOLOGY AND REHABILITATION 67

Dedication

We dedicate this report to the memory of E. Lynn Jenkins, PhD, who served as 

a senior editor of the report. She passed away unexpectedly in January 2014. 

Lynn had a distinguished career in injury and violence prevention with standout 

contributions in a variety of areas including workplace violence prevention. 

Her stewardship was critical to the completion of this report.
U.S. Department of Health and Human Servic

Centers for Disease Control and Prevention

National Center for Injury Prevention and Control

Division of Unintentional Injury Prevention

www.cdc.gov/inju

CS261967-A